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HomeMy WebLinkAbout0081 FARM VALLEY ROAD - Health 81 FARIt�"V�LLB SAD r r _ r a a G B i. Oq Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t 81 Farm Valley Road , 01 Property Address Farm Valley Road Realty Trust Owner Owner's Name information is Osteryille ✓ MA 02655 . 07/23/2020 required for every + s 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 forms A. Inspector Information on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road Company Address • Teaticket Ma. 02536 City/Town State Zip Code n 508-280-3356 S13938 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 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts .. Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Farm Valley Road Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 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: This 4 bedroom home has an H-10 1500 gallon septic tank with and H-20 D-Box feeding a 23'X 39' leaching field. At the time of the inspection no visible failure criteria was found. 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Farm Valley Road Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 page. City/Town 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 FIND (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 require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �d p Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. 81 Farm Valley Road u Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 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: 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 Inspe:tion Form:Subsurface Sewage Disposal System•Page 4 of 18 r'A Commonwealth of Massachusetts Title 5 Official Inspection Form lI p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ 81 Farm Valley Road Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 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 Y2 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 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c !% 81 Farm Valley Road u Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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 P 9 P Y 9 Commonwealth of Massachusetts Title 5 Official . Inspection Form Subsurface Sewage Disposal System Form -Not for Vol untary.Assessments 81 Farm Valley Road Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 44plus GPD Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d town water 9 ( Y 9 (gp ))� Detail: In 2019-33,000 gallons were used and in 2018-24,000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �n I� Title 5 Official Inspection Fora 11b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Farm Valley Road Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 page. City/Town 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: 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 '- <yI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 81 Farm Valley Road Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 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 ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 22"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form '? I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 81 Farm Valley Road Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 14"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: H-10 1500 gallon Sludge depth: 3„ Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" I Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts �v ,o Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .�� 81 Farm Valley Road Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 page. City(rown 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: bate 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts �v a Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Farm Valley Road Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 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.): i *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.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. l t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts �n = e Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . �/% 81 Farm Valley Road Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 page. Cityrrown 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: One 23'X 39' ❑ 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form yI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Farm Valley Road u Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 page. Citylrown 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.): At the time of the inspection no visibie failure criteria was found. 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 I c Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 81 Farm Valley Road Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 page. City/Town 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 81 Farm Valley Road Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 page. City/Town 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 i A 1prpnT a a O 19 ' a 136 t9 3 ti "�✓� t 3 Y6 3a 131 19 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts �v Title 5 Official Inspection Form +_ <1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 81 Farm Valley Road Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 page. Citylrown 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: 12 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit. 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 �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Farm Valley Road Property Address Farm Valley Road Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 07/23/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 jL Commonwealth of Massachusetts W f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 81 Farm Valley Rd. Property Address a\ Q Robin Schwartz `1 -I� ' 03C Owner Owner's Name information is required for Osterville Ma. 02655 2i22/2008 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. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not use the return Name of Inspector key. Capewide Enterprises,LLC 4i Company Name tIlIll rae P.O.Box 763 Company Address Centerville Ma. 02632 rerwq City/Town State Zip Code (508)428-4028 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails =; r r.'n C ❑ Needs Further Evaluati . y the Local Approving Authority / `-=1 2/22/2008 i Aga Inspecters Signziik re Date o j The system inspector shall submit a copy of this inspection report to the Approv ng Auth�6rity (B_oard of Health or DEP)within 30 days of completing this inspection. If the system is shared-syste6or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use . at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 81 Farm Valley Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments %M 81 Farm Valley Rd. Property Address Robin Schwartz Owner Owner's Name information is required for Osterville Ma. 02655 2/22/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑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. ND 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 ❑ obstruction is removed 81 Farm Valley Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Farm.Valley Rd. Property Address Robin Schwartz Owner Owner's Name information is required for Osterville Ma. 02655 2/22/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: 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 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. 81 Farm Valley Rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments 81 Farm Valley Rd. Property Address Robin Schwartz Owner Owner's Name information is required for Osterville Ma. 02655 2/22/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis; performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: J 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 ❑ ® 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. 81 Farm Valley Rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Farm Valley Rd. Property Address Robin Schwartz Owner Owner's Name information is required for Osterville Ma. 02655 2/22/2008 every page. City/Town, State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 81 Farm Valley Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c,M 81 Farm Valley Rd. Property Address Robin Schwartz Owner Owner's Name information is required for Osterville Ma. 02655 2/22/2008 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? El ® 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: N ❑ 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)] 81 Farm Valley Rd.•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 81 Farm Valley Rd. Property Address Robin Schwartz Owner Owner's Name information is required for Osterville Ma. 02655 2/22/2008 every page. City/Town, State Zip Code Date of Inspection 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 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage (gpd)): NA 9 ( Y 9 Sump pump? ❑ Yes ® No Last date of occupancy: Date 008 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: Last date of occupancy/use: Date Other(describe): 81 Farm Valley Rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Farm Valley Rd. Property Address Robin Schwartz Owner Owner's Name information is required for Osterville Ma. 02655 2/22/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes 0 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 81 Farm Valley Rd.•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts W . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1M 81 Farm Valley Rd. )Property Address Robin Schwartz Owner Owner's Name information is required for Osterville Ma. 02655 2/22/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.Noevidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): - Depth below grade: 16" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) r If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach 8 copy of certificate) ❑ Yes ❑ -No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1500 gallon H2O 2„ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 0 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 14" How were dimensions determined? Measured 81 Farm Valley Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 81 Farm Valley Rd. Property Address Robin Schwartz Owner Owner's Name information is required for Osterville Ma. 02655 2/22/2008 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.): Pump septic tank every 2 years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank is structurally sound. Grease Trap (locate on site.plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): 81 Farm Valley Rd.'-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Farm Valley Rd. Property Address Robin Schwartz Owner Owner's Name information is Osterville Ma. 02655 2/22/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is Ievel.Box has four outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage intoor out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 81 Farm Valley Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 81 Farm Valley Rd. Property Address Robin Schwartz Owner Owner's Name information is required for Osterville Ma. 02655 2/22/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 23'x39'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 evidence of hydraulic failure.Leaching field was dry at time of inspection. i 81 Farm Valley Rd.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 - i Commonwealth of Massachusetts r . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Farm Valley Rd. Property Address Robin Schwartz Owner Owner's Name information is required for Osterville Ma. 02655 2/22/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): 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.): 81 Farm Valley Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Map Page 1 of 2 Town'of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ❑ Zoom Out (J;�„�J J J J In ,07N LO 1 a r 9 �i r' > --.20 Feet Set Scale 1 20 I Aerial Photos r—...;nh4 )nnr-')nn7 T—A—of tlnmefohlo KAA All rinhfc roconn http://www;town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=097030&map... 2/23/2008 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Farm Valley Rd. Property Address Robin Schwartz Owner Owner's Name information is required for Osterville Ma. 02655 2/22/2008 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 15' 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: 1997 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:Gaherty& Miller model 12/16/94 ground water elevations.USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 Plate#2 annual ranges of ground water elevations. 81 Farm Valley Rd.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Town of Barnstable OF THE r, ti� Regulatory Services B►RxsrAs Thomas F. Geiler,Director' 9� 039i .`��' ArE Public Health .Division Thomas McKean, Director . 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This-septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. --- ()aO Fee---- BOARD OF HEALTH TOWN OF BARNSTABLE Application-*rlVrlt 0 tructionpermit Application is hereby made f permit to Construct 7) AIter or Repair ( )an individual Well at: or qonst -------'IX-------- Eocatfion' Address Assessors Map�nd,. RclParcel -.AAA Owner Address ------- ------tAcjv,f-V ------ r-CUICA V CAO Installer - Driller Q Address Q24,3 Type of Building Dwelling -0— ------------- Other - Type of Building —------------------ No. of Persons-_------------__-------------__ __ Type of Well Capacity-----------------------— — - - —— Purpose of Well------------ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private W Protecti Regulation The undersigned further agrees not to place the well in operation until a erVWpeate ompli nc een issued by the Board of Health. tec' SigQed7: - - - ------- — - ��(� --- 2 Application Approved By— hate Application Disapproved for the following reasons: —-----------—--------- ----------- ——---------------—-------------------------------------------------------- date Permit No. ------------------ date I'Jam 6 00 Issued Wu_/o -------------- ---- - - ------------------------------------------I--------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, hat the,Individual Well Constructed /), Altered or Repaired byCLOOL-Wil-/yi --------------------------------------------------------- at dlt�_ CPA Installer L ae-------------------------------------------------------------------- has been installed in accordance with ae provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ---------------Dated-------_---------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE —------—---------—------------ Inspector—---------------------------------------------------------------—--------- i - f, Fee---- BOARD OF HEALTH TOWN OF BARNSTABLE Application-*rWe7), AIter truct ion Permit Application is hereby made for a permit to Construct ), or Repair ( ian individual Well at: - { ----------- ----------� -------- 'M n���- Locatio ---- Assessors d Parcel �A n _ � Owner -"�--' ----- - - - ---_—_------- Address Installer - Driller Address Type of Building Q 3 Dwelling Q i - ------------ Other - Type of Building-------------------------------- No. of Persons----------------------------------------------- 1 Type of Well-.-- -T-— G`-' *-6 n)- 1 - -- ---- Purpose of Well---------- - - �-- ------- Agreement: The undersigned agrees to install the aforedescribed individual well iri' accordance with the provisions of The Town of Barnstable Board of Health Private W ll Protection Regulation The undersigned further agrees not to .place the well in operation until a er i ' ate .Xomplianc ' as.-been issued by the Board of Health. — — - �6- Signed - --------------------- �--� ate - ---- 1 Application Approved By-- - - -- - -- ------- - iate Application Disapproved for the following reasons:---------------------`---_____—____________________—____�__—_____ - —-- ------------- — ---— — - - f'-� —�� `- - ------------------------date ---- f Permit No. r -— -- Issued -- _ : te------------- - --- I '-------------------------------------------------------------------------------------------------------- i i BOARD OF HEALTH TOWN OF BARNSTABLE f 7' (Certificate ®f Compliance THIS IS TO CERTIFY, That the Indivi ual Well Constructed Altered ( ), or Repaired ( ) 4 by------`-� _�14_- �`� 1 -- -- ----------------- -- �j-------�---------------------------------- � - - -- Installer at1- -c-ay ---�_ -IP----------------------------------------------- has been installed -- - in accordance with a provisions of the Town of Barnstable Board of Health Private Well Protection f Regulation as described in the application for Well Construction Permit No. -------------------------Dated------------------------ i THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. f DATE------------------ - —---------------------- --- -- Inspector--- - - ---- ---—-------------------------------------------------------------------------------------_'�-----------�- j I BOARD OF HEALTH i TOWN OF BARNSTABLE Well Con5truct ion Permit No.WL-M 0 Fee-- j , Permission is ereby granted ^YAII�-ll- � �'.s1�_�-------- to Cons uct Alter'( ), or/�Repair ( ) an Individual Well a : No. — ----- �/1-— t.'� -- --•---i-eei(J'6Ef �'-V-I'f o-------------------------------------------------------------- as shown on the application for a Well onstruction Permit No. �� --------------—------- - Dated---7--�--- �--------------------------------------------------- - ----------------- ---------- Board of Health DATE - -- -- — -- I 1 f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 81 Farm Valley Road Osterville, MA 02655 Owner's Name: David&Francine Walsh Owner's Address: w SAW Date of Inspection: August 9, 2005 Name of Inspector: (Please Print) James M. Ford t - Company Name: James M. Ford Mailing Address: P.O.Box 49 ry Osterville,MA 02655-0049 c` e-� � Rx Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the inforttlation-reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: August 13, 2005 . The system inspector shall subm copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. 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 in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 81 Farm Valley Road Osterville, MA Owner: David&Francine Walsh Date of Inspection: August 9. 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND 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 obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 81 Farm Valley Road Osterville, MA Owner: David&Francine Walsh Date of Inspection: August 9. 2005 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 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 I 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 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSES SMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 81 Farm Valley Road Osterville. MA Owner: David&Francine Walsh Date of Inspection: August 9. 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6".below invert or available volume is less than ''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 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) 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. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 81 Farm Valley Road Osterville. AM Owner: David&Francine Walsh Date of Inspection: August 9, 2005 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 breakout? ✓ _ 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: Yes No ✓ _ 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 1$.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 81 Farm Valley Road Osterville, MA Owner: David&Francine Walsh Date of Inspection: August 9. 2005 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry,on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currentiv occupied COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed in 1997-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 Farm Valley Road Osterville, MA Owner: David&Francine Walsh Date of Inspection: August 9, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): l� 1 SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16" 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): (attach a copy of certificate) Dimensions: 1500 rzal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffler 30" Scum thickness: 5" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.): .Tees were present. The liquid level was even with the outlet invert. There did not appear to be any sins of leakage GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: 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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 Farm Valley Road Osterville, MA Owner: David&Francine Walsh Date of Inspection: August 9, 2005 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): The D-box was clean with no solids. Sneed levelers were present PUMP CHAMBER: None (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 of pumps and appurtenances,etc.): 8 I Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 81 Farm Valley Road _ Osterville. MA Owner: David&Francine Walsh Date of Inspection: August 9, 2005 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: 23'x 39' -per as built card 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.): There did not appear to be any signs of backup or failure. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 81 Farm Valley Road Osterville, MA Owner: David&Francine Walsh Date of Inspection: Auzust 9, 2005 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. 'Pr6Ar OIL t Q O is a i3� iq ti 3 Y� 3a 3 y 3`7 119 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 81 Farm Valley Road Osterville, MA Owner: David&Francine Walsh Date of Inspection: August 9, 2005 SITE EXAM Slope 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 of SAS) Checked with local Board of Health-explain: topographic and water contours mans Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: According to the design plans on file no water was observed at I P below grade when the system was installed This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty'or guarantee that the system will function.properly in the future. There have been no warranties or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report. 11 TOWN OF BARNSTA.BLE v LOCATION PAfM AI[! SEWAGE # q12/q.r VILLAGE os-ary k ASSESSOR'S MAP & LOT D 91 0 P INSTALLER'S NAMF,&PHONE NO. l,LS SEPTIC TANK CAPACITY t S(� LEACHING FACII= (type) GL, ,J � (size) a3 x 3 9 � NO.OF BEDROOMS BUILDER OR OWNER 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 leachii g facility) Feet Furnished by a i O n B 3 Y� 3a y 3`1 19 s TOWN OF BARNSTABLE, -LOCATION /_.rd-OdM LZ96ki� 2b SEWAGE g — 9 i`vILLAOE_MZE& Vice L ASSESSOR`?MAP i,YSTALLER'S NAME&PHONE NO.�, � G_ �'� — SEPTIC TANK CAPACITY �/.'SDO ?[vw c�7rm�19/Z7rr�� �T LEACHING FACILITY: (type) ,gAr h/ 5k-A A- (size) 6 NO.OF BEDROOMS._.._" BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Mvimum Adjusted Croundwater 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 Edge., 300 fee leaching facility , / � A Feet Furnished by TOWN.OF BARNSTABLE LOCATION SEWAGE # �''L.LAGE ASSESSOR'S MAP & LOT _ INS'TALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) 1 NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 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'o Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by rl t Z 77 la Zt7 37 1 ` ( 1 ` ( C e No. 9 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Apprication for W9pont *pgtem Construction Vermtt Application for a Permit to Construct( 4Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ��j�j Owner's Name,Address and Tel.No. f7 / F=6f2AA \jAL1_M-Y ZoAt> 'DAVID +FEZ Iffda(WE wAL-sb� Assessor's Map/Parcel 32 W 1 L'DV(/C2Cov D,7kvG 9-1 3a 540Z,30e44 /K4• Installer's Name,Address,and Tel.No. Designer's Name,Address aai�d Tel.No. $4)trle2 Ao WC We- 61-7- A4A IN '77- O Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq-€t. Garbage Grinder( °� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow -D gallons per day. Calculated daily flow 40 gallons. Plan Date A)t- 22g IR9'1 Number of sheets ( Revision Date Title 1' `DA0*Q + -IZA-QeA G_r Yt/"14 Size of Septic Tank l 2 Cou R L() Type of S.A.S. FI EL'D - 3q l x23' I tI ' If it it II p �" Description of Soil !� - 2 2 �(� E 6e-'# LoAnnN Saute 13 2� - 132 M� kmr� C Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and mainten nce of the afore described on-site sewage disposal system in accordance with the provisions of f the Environm to ode and not to place the system in operation until a Certifi- cate of Compliance has been iss ed y thi Bo of H Signed Date Application Approved by Date ` '-t Application Disapproved for the following reasons Permit No. '� Date Issued •, No, � _ Fee 7 THE COMMONWEALTH O,F MASSACHUSETTS . Entered in computer: �. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppricattou for MigpogaF*pztem Cougtructtou Permit Application for a Permit to ConstrtWt(` Repair( )Upgrade( )Abandon( ) El Complete System O Individual Components `'Locati'on Address or Lot No. Owner's Name,Address and Tel.No. ff/ 17-tlrZAA, VAI�t_M-y D STvZ_Jm_t,6 'DAViD + r pNGrNE WAL-59 Assessor's Map/Parcel 32 V I C.AW oeaD VrzkvG 9-7 1' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. w 5QXTEe e,. 41c IIJC- 9 . �1Z A4AIN "77 O I—v I L.c.c M A, { s Type of Building: Dwelling No.of Bedrooms Lot Size 112 Qe- Garbage Grinder( .q/ Other Type of Building No.of Persons Showers( ) Cafeteria( ) 3` Other Fixtures hfl ' hevision Design Flow Ll�-f7 gallons per day. Calculated dailyt ��-O gallons.Plan Date AP7.IL- 2Z, I IqI Number of sheets i Date YF_ Title r— F_ `!?A Vlb 4 11`'I7A 00 M 1d. -5 r `. Size of Septic Tank • / Cou Tyn eof S.A . M ELD t Description of Soil.I_. - 2 f 'Z ' E ,(o'— d- LOAn%1�1' u� , - - 132 ME'-. �Agci t^ t Nature of Repairs or Alterations(Answer when'applicah1e65Xr .._:' } •i . •� a .. _....a.. ww, .,. MrMi+w ~" Datelast inspected: Agreement 5 yyqq ! The undersigned agrees to'ensure the construction and maintet j nce of the of i e described on-site sewage disposal ystem in accordan a with the provisions of T4de-:&of the+Environmental bode and not to place the system/in operation until a Certifi- ` �� cate of Compliance has been iss ed thi Bo!l of He t f¢'" r•_� �1 l I. Signed , Date _11 f' Application Approved by /' ' -Date III A licationDisa roved for the following reasons PP PP g Z S [ R, •Y'6l f . 'C �.x ��_ � �`, s [ y.. N R n v• ��,n _ �Permit No. y / • Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( v<Repaired( )Upgraded( ) Abandoned( y at_R/ — eras been constructed in accordance 5 and the for Disposal System Construction Permit No. ' dated with the provisions of Title Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as desig ed. Date ( Inspector No.�/_e�------------------------Fee �yUre.- THE COMMONWEALTH OF MASSACHUSETTZS., PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1=igpoga1 "tem cougtructiou Vermit Permission is hereby granted to C nstruct( Repair( )Upgrade( don ) System located and as described in the above Application for Disposal System Construction Permit. The applicant recognize s/he duty to comply with Title 5 and the following local provisions or special conditions. x Provided: Constructi must be feted within three years of the date of thi it. Date: Approved by D i i TOWN OF BARNSTABLE. LOCATION / SEWAGE# ! — 9 7' VILLAGE ASSESSOR'S MAP&LOT�—D30 INSTALLER'S NAME&PHONE NO. G ' — SEPTIC TANK CAPACM DO ?4>v /3r2 LEACHING FACILITY: (type) .h_�Gr�/ 6_`tl (size) 23 ' g 3 4' NO.OF BEDROOMS BUILDER OR OWNER 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 walls exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(if any wetlands exist within 30D fee leaching facility) Feet Furnished by t 4 �. 37 / q _0 � 1 � 1 � I - 1 f r _ 1 p ' i b � A i Z/E'd 2-69 ON SSwSLL osm %iaiinS XISAUS WtiTT:6 L66T'ST*AON C�TY[Tyr The Town of Barnstable •' Health Department 367 Main Street, Hyannis, MA 02601 �0 Y�Y In Office 508-790-6265 Thomas A. McKean FAX 508-775-3344 Director of Public Health February 5, 1993 Charles D. Rogers, Trs. South County Trust West Barnstable Road Osterville, MA 02655 i ORDER TO ABATE VIOLATIONS OF 105 CMR 410.00, STATE SANITARY CODE 112 MINIMUM STANDARDS OF FITNESS: FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE BOARD OF HEALTH'S NUISANCE CONTROL REGULATION NUMBER ONE The property owned by you located at Farm Valley Road, Osterville, MA, was inspected on February 3, 1993 by Donna Miorandi, Health Inspector for the Town of Barnstable, because of a complaint. The following violations of 105 CMR 410.00, State Sanitary Code 11, Minimum Standards of Fitness for Human Habitation were observed:.. 410.602 (A): Household.rubbish dumped on land known as Map 097, Parcel 0304_ You are directed to correct this violation within two days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health at Town Hall; 367 Main Street, Hyannis, within seven (7) days after the date order is received. However, these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with An order shall constitute a separate violation. You are also subject to non-criminal citations of $40.00 for the first violation. and .$15.00 for each additional violation. Tickets will be issued daily until the violations are corrected. PER ORDER OF THE BOARD OF HEALTH Zas;Mc fe Director of Public Health TOWN OF BARNSTABLE TM/bcs Certified - P375763344 w J 1.3 3 710,00 j 4IV e p Pv. It 1 q3 AC 'i'o r`'►� x �� zs 54 `� Nis 09 AN- > f i:iA ,t �rJ 1 3 Z9 . 92 UPLAND 9 a I OZUP►AND. OZ wET rzl \ .93 UPI HO p S T ,1 (�WE"r . 94 AC TOTAL \ . Z4 WET \ 1..18 AC ToTA'- 111 1,17 AC- C M- I Z�- 14�9 3 O ho ^� '1` i � 2-7 �,r� L As-T N+o. U s eb. 37 3 . 8p�UPLAND PE ND ru �� 3e 1,07 UPLAND " v .O 1 WET REV BY AV/S rU Q 4 3 AC TOTAL 'I 1 , 08 AC TOTAL_ © ,JG G rro RIGINAL ISSUE : N0. NOT USED. 18 rq ALL 77 98 121 `UT / �� 3qo 76 97 120 ILL 75 96 119 f � r,rpy A,k b F a�� L � ., to a� •' ,�'v �, }'`- � w ett,�": r ' I F• _ N soGT O ti -ALL COMPONENTS LOCATED IN POTENTIAL VEHICLE TRAFFIC-AREAS OR BURIED 4 FEET JP G RI COVERS LOCATED TO , - OR -GREATER SHALL BE H-20 LOAD CAPACITY:. _ - SMOKE 2� 12": OF F.G . RO Pp TEST HOLEco = ACME PRECAST P-8738 TOP of QB3 OR EQUAL ELEV.= 22,[) F-G. 21'f BAXTER & NYE INC. LACUs ? FOUNDATION \.��, \.�\.� ��\ F.G. 21'f JUtY 30,1996 a . INV. = 19.0 .1.500 GA 20f PIT #1 4' /• T ELEV. = 19.9 IN V._ H2O�ES1GN 4 DIAMETER T -0„ /�► 18.8 2 COMPARTMENT IN-V. _ 8.6 DTST. SCHED 4Q _ 2 LOCUS MAP INV. =18.4 USE = LOAMY SAND - E sEtrnc TANK eox v.C. p�E TOP ELEV. 18.5 INV. =18.2 - -6" SCALE 1 25,000 10.00' 6„ -CRUSHED INV. = 18.0 .:;: ...: .•;•., :.°•-:: ..�.•... ,,.., LOAMY SAND - B ASSESSORS BASEMENT FL. EL. 14.5 MIN. : . STONE BASE �• + '> t:.� * s y, .. ..:•: •+ :" .r �. i.�• y•,.w 'Jl'.. J.. :.,.,i , .�:..,;: : ,.. MAP 97 PARCELS 29-32 BOTTOM ELEV:17.0 MEDIUM SAND - C -48" PERK TEST GRAPHIC SCALE 0 20 40 00 -EL. 11.6 CAL. HIGH WATER - LOT 140 T.H. = EL. 8.9 EL. 8.9 -132" NO WATER ELEVATIONS ARE BASED ON N.G.V.D. NO SCALE FLOOD PLANE LINE IS BASED ON FLOOD INSURANCE RATE MAP " IGN DATA COMMUNITY-PANEL NUMBER 250001 0018 0 REVISED: JULY 2,1992. SINGLE FAMILY- 4 BEDROOMS a' s' s• s• a• WITH 'GARBAGE GRINDER DAILY FLOW = 110 X 4 = 440 G.P.D. SEPTIC TANK = 440 X 200% = 880 G.P.D. Z Q USE 1500 GAL.TWO COMPARTMENT SEPTIC TA '2NK � COMPARTMEN f ONE 440 X 2 = 880 -G.P:D MIN. N= COMPARTMENT TWO 440 _X - • • 1 440_G.P_D. MIN. - A.• z mow. •: d • • • • • . • d . r LZCHM I IM DESIGN 3/4" TO 1 1/2„ ALL PIPES TO BE SCHEDULE 40 PVC* PERFORATEDWASHED STONE IJSE 4 4" DISTRIBUTION LINES 1N AN TOPPED WITH 2" OF PEASTONE go - 23'X 39' WASHED STONE -FIELD �--' AS SHOWN / SYSTEM IS WITHIN 250' OF A RESOURCE AREA -CROSS SECTION C.8. SET \ / THEREFORE NO SIDEWALL AREA IS ALLOWED NO SCALE ` 23.0 440 G.P.D./.74 + 50% 6,33 892 S.F. OF BOTTOM AREA REQUIRED 'aly s' x)1 24.0 ✓` USE 23'X 39'= 8.97 S..F. AREA PROVIDED N' x lF CLASS 1 SOIL PERCOLATION RATE 1" IN 2 MIN. OR LESS C.H�ST '21, 24• I 23.0 / r/ f#1644 \ HYDRANT SPINDLE C.B. FND.. BENCHMARK = 24.8. x 22.6 / _ 21 15.8 T ✓ ;: 226 1' ,C.B. FND. 2 3.5 39• j . -A 92Z5 p \ cps ; � �• __ 't ,�' R� �� r .I. . . ... , 62. x 1).5 D h D / J �� '�� C.B.,FND. p. DIST. Q v p v. f V. F .. . .. . . .. 3 x 21.2 3/4" TO. 1 1/2" `�q��s/O �3• , :. ::.�. . WASHE-D STONE '9 ' TOPPED `WITH 3' OF PEASTONE 39 .. .. . . .. . . /f F OF -LEACH IEID 15 d (\20.0 I SCALE: l' = 10' i 19.5 ,•. . •..•. .� f� WETLAND 1 : . ... - - .. . .. . . .. . . .. i 21.3 i I I _j. . . . . .. .... . . ' ZOT 137 .. . . . .... . covered po ry 4 f. / T 13,E 19.4 F j Q X . . . 193 j / ARO 00 3 ZONE fi0 E 0) 4ti ,Q) 2Q D RESIDENCE F-1 Col/ere(, �Clyc ,o vl cb MINIMUMS r YYYY AREA = 43,560 S.F. Po ch 1$.7 ti FRONTAGE = 20' x� 7600, WIDTH = 125' FRONT SETBACK = 30' �� 18.4 f- SIDE SETBACKS = 15' REAR SETBACK = 15' x 15.5 r► f�` BUILDING HEIGHT = 30' ,: -__ CLUSTER SUBDIVISION / �����6'"�P • , &0 PLAN DATED JANUARY 28,1988 TOTAL ACRES 27.26 TOTAL NUMBER OF LOTS : 12 4 ORIGINAL LOTS (116-119) 8 REVISED LOTS (133-140) AVERAGE AREA PER LOT = 2.27 ACRES 9.9 C3 \ x14.5 j `°• C .C4.5 C4 10.0 lz6 } 3 / �v \4. � 10.9 x , C2 - C5.5 x 131 x 16.3 �L C6 Ji / �Ii` .y ; Cl f x Y6.3 k.! i WETLAND 14-1 C7 � / �, J, �, .t, SILT FENCE WETLAND 1.3_6 y 110 :'`, % --- j, `L `L - `1' �I, TRENCH x .,r/7) - Cl 2,928 sq.ft. Wetland \i 11.2 11.3 �� 46,039 sq.ft. upland �� C9 ;% x 15,3 KEY SILT FENCE INTO TOTAL �`_---..--_ _ _ _� .� ' ,1, �, �, �, �, GROUND 4" TO 6" ' C.B. FND. 48,%7 S,F. x 14.6 STAKED HAY BALE DETAIL 1,12 Ac. x 13.3 1.79,29, CO �� �780 x 13.6 \ �O S7'04. SITE PLAN OF LOT 138 - L.C.C. 5725-46 4s -NOTES B. FND. IN � -(�t) REMOVE-'UNSUITABLE SOILS-BENEATH PROPOSED`SYSTEM, -BACKFtIL. BENCHMARK 14.57 p � (OSTERVILLE & MARSTONS MILLS) NTH CLEAN-GRAN ItAR-MATERIAL FILL TO -BE GRADED AS-FOLLOWS: NOT h MORE THAN 1 \F__- F-FRACTION TIO No. S ING.N .4, 0%-O -T-LESHAU SAS.RETAINED BARNSTABLE MASS . � ON -No. 50.SlEVE,-_OFF-RAGIi.ON PASSING.Na. .4, _1O�.DR-LESS .TO PASS No. PLAN �T ' 100 SIEVE AND 5% OR LESS TO PASS No. 200 SIEVE, SOIL TO BE APPROVED A BY ENGINEER FOR COMPLIANCE PRIOR TO PLACING ON SITE. �V (2) LOCATION"OF'-UTILITIES- NOT SHOWN ON-THIS PLAN, AT LEAST 72 HOURS SCALE: 1" = 20' FOR �. PRIOR-TO-��-{-�ECA�TI6P{-FAR T+•IIS f'f20JECT-eONTRAC-�R-SH-ALL- MAKE _ DAV I D & FRAM C I N E WALS H Q THE REQUIRED---UOTIFICATION TO-DIG- SAFE-(I-800-322-4844) AND APPROPRIATE WATER DISTRICT TO DETERMINE UTILITY._LOCATI.ONS. SCALE: AS NOTED DATE: APRIL 22,1997 NOTES ZONES BAXTER & NYE INC. O FOR ALL ASPECTS-OF--THE-sEPTIC: SYSTEM-THE-CONTRACTOR G.P. & W.P. REGISTERED LAND SURVEYORS SHALL COMPLY--WITH ALL-GOVERNING CODES AND'REGULATIONS. -NOTES CIVIL ENGINEERS ❑STERVILLE, MASS, IN PARTICULAR 310CMR 15:000 THE -STATE ENVIRONMENTAL CODE TITLE 5, LOT COVERAGE: THE TOWN OF BARNSTABLE BOARD OF HEALTH REGULATIONS PART VIII: ON-SITE SEWAGE DISPOSAL REGULATIONS AND THE BOARD OF HEALTH HOF NO MORE THAN FIFTY PERCENT (50%) OF THE TOTAL UPLAND AREA RECOMMENDATIONS FORACCEPTED PRACTICE. OF ANY LOT SHALL BE MADE IMPERVIOUS BY THE INSTALLATION OF �of \;.- � PETER � TWO COMPARTMENT SEPTIC TANK REQUIRES 2 WEEKS# LEAD TIME BUILDINGS, STRUCTURES AND PAVED SURFACES. SULLIVAN � /� TO ORDER FROM SUPPLIER. gp�pp NO.29733 N V S SITE CLEARING: A. CIVIL THE SEPTIC TANK'S FIRST COMPARTMENT SHALL BE SIZED FOR 880 GALLONS MIN. So� THE SECOND COMPARTMENT SHALL BE 'SIZED FOR 440 GALLONS MIN. ALL IN ACCORDANCE WITH 310CMR 15.224 MULTIPLE COMPARTMENT TANKS. A MINIMUM OF. THIRTY PER.C.EUT (34%) -OF THE TOTAL.-UPLAND--AREA� - �Qr ��! :• TWO TANKS IN SERIES MAY BE SUBSTITUTED SUCH THAT THE FIRST TAWOF ANY LOT SHALL BE RETAINED IN ITS NATURAL STATE, WITH I O IS 1500 GALLONS & THE SECOND TANK IS 1000 GALtONs AS PER 15:225. - - ONLY LIMITED SELECTIVE CUTTING OF TREES AND CLEARING OF UNDERSTORY SHRUBS AND GROUNDCOVER ALLOWED. wC,�, #97025A