HomeMy WebLinkAbout0084 FARM VALLEY ROAD - Health 84 FARM VALLEY ROQD
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Commonwealth of(Massachusetts
Title 5 Official Inspection Fora, COPY
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 Farm Valley-Road
Property Address --- ---- — _-----
Gail LaPrade
Owner Owner's Name
information is Osterville _MA 02655 Ma 7, 2014
required for every _ _—
page. CityfTown 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. General Information
on the computer, y
use only the tab 1. Inspector: V
key to move your
cursor-do not Patrick T. Sullivan
use the return Name of Inspector
key.
Ready Rooter Excavating_
Company Name
P.O._Box 89
Company Address
few Forestdale _ MA 02644 _
City/Town State Zip Code
508-888-6055 _ SI12843
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
.� � z _- May 20, 2014 -- --------
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days-of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
51MIIJ
t5ins•3/13 Title 5 Official InspIFForm: ?,fac.ege Disposal System•Page 1 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 Farm Valley Road
Property Address
Gail LaPrade
Owner Owner's Name
information is Osteryille
required for every MA 1�_ 02655 May 7, 2014
-- ___ _
page. Cityrrown State Zip Code Date of Inspection
Bo 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:
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.
Fr
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#ith a complying septic tank as approved by the Board of
Health. ���
* A metal septic tank will pass inspec�Mon if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank,s less than 20 years old,is available.
❑ Y ❑ N ❑IN D (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I
M 84 Farm Valley Road
Property Address
Gail LaPrade _
Owner Owner's Name
information is y Osterville MA 02655 May 7 2014
required for every _— — � __—
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or/high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board ofiHealth):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed �`/ ❑ Y ❑ N ❑ ND (Explain below).
r
❑ 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 Heelth):
❑ broken pipe(s) are replaced ❑ Y ❑,N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y j❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
I
❑ 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 environmen�l'
i
❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 Farm Valley_Road
Property Address
Gail LaPrade _
Owner Owners Name
information is y ,Osterville MA 02655 May 7 2014
required for every -__ _
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary t a surface water supply.
❑ The system has a septic tank and SAS a d the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SA and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS nd 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 wate analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent an the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that o 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
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
❑ ® 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/z day flow
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 Farm Valley Road
Property Address
Gail LaPrade _
Owner Owner's Name
information is Y Osterville MA 02655 May 7 2014
required for every ,
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
i
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- I
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 sy/sten
i 400 feet of a surface drinking water supply
❑ ❑ the syin 200 feet of a tributary to a surface drinking water supply
❑ ❑ the syted in a nitrogen sensitive area (Interim Wellhead Protection
Area mapped Zone II of.a public water supply well
If you have answered "yes" tion in Section E the system is considered a significant threat,or answered "yes" in Sectioe 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 owrer should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 Farm Valley Road
Property Address
Gail LaPrade _
Owner Owner's Name
information is Osterville _ MA_ 02655 May 7 2014
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?
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:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 -- Number of bedrooms (actual): 4 --
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 666 GPD
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 84 Farm Valley Road
Property Address
Gail LaPrade
Owner Owner's Name
information is Osterville MA 02655 Ma 7, 2014
required for every _ —_ _ ____y _
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
stem is designed for a four bedroom home with a garbage disposal.
Number of current residents: —
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
s
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): 2012-2013 over
900 GPD
Detail:
Water readings are high due to irrigation during summer months.
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
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/s etc.): —
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank pr ent? ❑ Yes ❑ No
Non-sanitary waste dischar d to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if I ailable: —
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 84 Farm Valley Road _
Property Address
Gail LaPrade
Owner Owner's Name
information is
required for every Osterville MA _ 02655 _ May 7, 2014 _
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Ready Rooter records: Pumped June 2012
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? Site tube on truck
Reason for pumping: Maintenance S
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 84 Farm Valley Road
Property Address
Gail LaPrade _
Owner Owner's Name
information is Y ,Osterville MA 02655 May 7 2014
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:
System installed 10/27/1999. Certificate of Compliance on file at Board of Health.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 210"
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: n/a _
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: 2
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: 10.5' X 5.5' X 5.5' 2 Comp, 1500
— —
Sludge depth: 4 -- -
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 Farm Valley Road
Property Address
Gail LaPrade__
Owner Owner's Name
information is Osteryille MA 02655 May 7, 2014
required for every ----
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29
Scum thickness 6 -- -
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 8
How were dimensions determined? Tape measure and dip tube.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet and outlet PVC tees in place in both compartments. Liquid level at outlet inverts. Risers bring
covers within 6" of grade. Recommend maintenance pumping of first compartment and cleaning
effluent filter in second compartment every year. Recommend pumping and cleaning entire tank
every four years.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal /6 fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness ---_--
r
Distance from top of scum to`top of outlet tee or baffle
Distance from bottom of um to bottom of outlet tee or baffle ----- ---- —
Date of last pumping: Date
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ,•'' 84 Farm Valley Road _
Property Address —
Gail LaPrade
Owner Owner's Name
information is
required for every Osterville MA 02655 May 7, 2014
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 fi rglass ❑ polyethylene ❑ other(explain):
i
Dimensions: - — — —
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: f, Date
Comments (condition pf alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
x Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 Farm Valley Road
Property Address
Gail LaPrade _
Owner Owner's Name
information is Osteryille MA 02655 May 7 2014
required for every _ _ Y
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan): ;
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.)-.
One inlet, three outlets, no speed levelers in place. No solids carryover. No sign of high water staining
over outlet inverts. D-box is located at edge of driveway.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ -Yes ❑ No*
Comments (note condition of pump ch ber, condition of pumps and appurtenances, etc.):
------------
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
if SAS not located, explain why:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•''y 84 Farm Valley Road
Property Address
Gail LaPrade
Owner Owner's Name
information is Osterville MA 02655 May 7, 2014 _required for every __ _ y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number: — —
❑ leaching chambers number: -
❑ leaching galleries number:
❑ leaching trenches number, length: —
® leaching fields number, dimensions: 1-501 X 18'W X16"D
❑ 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.):
Camera used to inspect SAS through vent. No sign of past hydraulic failure.
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} flow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Farm Valley Road
Property Address
Gail LaPrade
Owner Owner's Name
information is Osterville MA 02655 May 7, 2014
required for every - — -- -
page. Cityfrown 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.):
I
E"
Privy (locate on site plan):
Materials of construction:
Dimensions — --
Depth of solids — ---
Comments (note condition of soil, igns of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form -
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Farm Valley Road
Property Address
Gail LaPrade _
Owner Owner's Name
information is required for every Osterville MA 02655 May 7, 2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (coot.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
I
t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
I -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
84 Farm Valley Road
Property Address
Gail LaPrade
Owner Owner's Name
require for
is Osterville MA _ 02655_ May 7, 2014
required for every _ _ y
page. Cityrrown 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: 5
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed. _Date
1995
ate
❑ 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:
maps.massgis.state.ma.us/oliver.php _
You must describe how you established the'high ground water elevation:
Test hole in 1995 shows adjusted ground water at elv= 11.6. Base of SAS at elv= 16.6 per
engineered plans. Accessed local ground water contours and topo mapping.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 84 Farm Valley Road _
Property Address
Gail LaPrade
Owner Owner's Name
information is Cisterville MA 02655 May 7 2014
required for every _ Y
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® inspection Summary: A, B, C, D, or E checked
k
® 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
i
z
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
l
TOWN OF BARNSTABLE
LOCATION �� �Arw� ��\���( R� SEWAGE#
VILLAGE ASSESSOR'S MAP.&PARCEL C O3
INSTALLER'S NAME&PHONE NO. e�
SEPTIC TANK CAPACITY
LEACHING FACILITY.(type) (size) Ste`L- K g t GJ X k6
NO.OF BEDROOMS Li
OWNER G442.-, � Ld�s�c��
PERMIT DATE: 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 e�c�,�1 �,�c���J� s✓,Q�`.pC`�V�
Y(\/\A\( 71
aLi ' !
� = 3� 6
TOWN OF,BARNSTABLE , L
LOCATIONS (�� �y �� SEWAGE#
VILLAGE ASSESSOR'S MAP &-LOT -o 3
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1�01> k,/J2/A,,,rMhA
LEACHING FACILITY: (type) j"l-f l (size) S•d� X 1p,4
NO.OF BEDROOMS '
BUILDER OR OWNER IU0,,,-M
PERMUDATE: Y— COMPLIANCE DATE: s a.?
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 6f,Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
f
8B
M
A.N.. ;Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Rpprication for Wgpo!gai *p.5tem Cori.5tructiou Vermit
Application for a Permit to Construct()()Repair( )Upgrade( )Abandon( ) '0 Complete System ❑Individual Components
Location Address or Lot No. S* Firen Uc tic-A QJ Owner's Name,Address and Tel.No.
(-a-r 13R� i.Gc: 5725-46 h'Ir %� Me's lj. "pv*ae
Assessor'sMap/Parcel 1 TO Xrwrrncss. Court
1144P 1m 1 o 4
Installer's Name
ddress,and Tel.No. Designer's Name,Address and Tel.No. 9 ZT-915
—7 7 f�J���► 2 rl7o.� . trr�� a 2G
Type of Building:
Dwelling No.of Bedrooms R r' Lot Size 45.3Z5 sq.ft. Garbage Grinder(V/
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow Qe imm = ,//O gallons per day. Calculated daily flow 4 40 gallons.
Plan Date /�S f x� Number of sheets &21r e_ Revision Date 2/251/tz-
Title
Size of Septic Tank i 5oo a o lluvt,a Type of S.A.S. 6.c-ck
Description of Soil 12CIZ , 4o 4,11 QtWnj ( P-- 8575
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 b o d
yleelllply
Signed / Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
I ,
TOWN OF BARNSTABLE �, U
LOCATION ! (��Zl/�y r SEWAGE # C l
VILLAGE ASSESSOR'S MAP & LOT 44-4- 3
INSTALLER'S NAME&PHONE N0. / '� �
SEPTIC TANK CAPACITY
LEACHING FACIL=: (type) —L�I
(size) 5-v' :< t'9'
NO. OF BEDROOMS q
BUILDER OR OWNER
PERMITDATE:_ L -61..�7 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)
Furnished by Feet
! G G
is
,! s i / .e D
u tNe
LY
THE COMMONWEALTH OF MASSACHUSETTS �' Enf're n computer: es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Application for"Mi!5poal 6pelem Construction Permit
Application for a Permit to Construct()()Repair( )Upgrade( )Abandon( ) 50 Complete System O Individual Components
Location Address or Lot No. `v 4 Farm Va if`°tg QJ Owner's Name,Address and Tel.No.
Lo-r 134 Lcc. 5772S-46 ft7r s Mrs 0. "rProck
Assessor's Map/Parcel I TO Xn u<r n es S. cou l&
44,9 do 97 G�r9ae L- l u 60044
Installer's Name ddress,and Tel.No. Designer's Name,Address and Tel.No. q ZO' cj l
ry��j j'�'�1J�'l� 1�✓o x(mo r N e,SWc-.
/KK// / -7�l iy�n�i B/2 maims �frrsr-
F
Type of Building:
Dwelling No.of Bedrooms Fnp Lot Size 45,3Z5 sq.ft. Garbage Grinder(Vf
Other- Type of Building No.of Persons Showers( ) Cafeteria( )
Of�r Fixtures l J
Design Flow .�« Oarccm = //O gallons per day. Calculated daily flow 440 gallons.
Plan Date //5./ y Number of sheets ,ome Revision Date R /23/
r Title
Size of Septic Tank 1500 n r�k k c" Type of S.A.S. _I.c.&ck F e(& So t lc t%
w
Description of Soil 1-C-6, 4. sn." x2 i eb h-Y as-)5
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: o d f� e
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. -- Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS..TO CERTIFY, that the On-site Sewage��l1ispposal S stem Constructed( Repaired( )Upgraded( )
Abando t Cp l
ed( ) y xl ae5z
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Cons ction Permit No. e dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date /0 + �1 Inspector ,.1J
q(?� r
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwigozaY pgtem Construction Permit
Permission is hereby granted to Construct( Re air( )U grade(` )Ab don
System located at
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 orspecial conditions.
Provided: Construction�ust be completed within three years of the date of this pe t.
Date: �/ G/// Approved by
-------- ---
NOTES so N
(D FOR ALL ASPECTS OF THE SEPTIC SYSTEM THE CONTRACTOR ZONES Ty 0
cf)
SHALL COMPLY WITH ALL GOVERNING CODES AND REGULATIONS, x GP & WP 74
IN PARTICULAR 310CMR 15.000 THE STATE ENVIRONMENTAL CODE TITLE 5, &
THE TOWN OF BARNSTABLE BOARD OF HEALTH REGULATIONS PART VIII:
RF-1
ON-SITE SEWAGE�,DISPOSAL REGULATIONS AND THE BOARD OF HEALTH
RECOMMENDATIONS FOR ACCEPTED PRACTICE. C.B. ,MISSING MINIMUMS
=
TWO COMPARTMENT SEPTIC TANK REQUIRES 2 WEEKS OF LEAD TIME 24.4 AREA 43,560 S.F.
x O FRONTAGE = 20'
TO,ORDER FROM SUPPLIER.
22.4 WIDTH = 125'
03 THE SEPTIC TANK-',S 'FIRST COMPARTMENT SHALL BE SIZED FOR 880 GALLONS MIN.,` FRONT SETBACK 30'
THE SECOND COMPARTMENT SHALL BE SIZED FOR 440 GALLONS MIN. 4' 4' c PAVED DRIVE SIDE SETBACKS 15' ums
x ALL IN ACCORDANCE WITH 310CMR 15.224 MULTIPLE COMPARTMENT TANKS. .cone. pad
TWO TANKS IN SERIES N 18.5
,MAY BE SUBSTITUTED SUCH THAT THE FIRST TANK REAR SETBACK 15'
IS' 1500 GALLONS & ,THE SECOND TANK IS 1000 GALLONS AS PER 15:225. 20.5
0,560C 23.4
BUILDING HEIGHT = 30'
20 SE
(D REMOVE UNSUITABLE SOILS BENEATH PROPOSED SYSTEM, BACKFILL ).4 C 13
SE �2.4 22.9 LOCUS
MORE THAN 15% RETAINED ON No. 4 SIEVE, NOT MORE THAN 90% RETAINED C. T _3 MAP
WITH CLEAN GRANULAR MATERIAL FILL TO BE GRADED AS FOLLOWS: NOT
55,00'
SECTION 3-1.7 it.o TP 22.79 1 SCALE 1 : 25,000
ON No. 50 SIEVE, OF FRACTION PASSING No. 4, 10% OR LESS TO PASS Na. 17.4\, (OPEN SPACE RESIDENTIAL DISTRICT)
100 SIEVE AND 5% OR .LESS TO PASS No. 200 SIEVE, SOIL TO BE APPROVED ASSESSORS
BY ENGINEER FOR COMPLIANCE PRIOR TO PLACING ON SITE. ZONING CRITERIA
23.0 22.0
17.9 MAP 97 PARCELS 31
LOCATION OF UTILITIES NOT SHOWN ON THIS PLAN, AT LEAST 72 HOURS x 19,0 C. SET x
PRIOR TO ANY EXCAVATION FOR THIS PROJECT CONTRACTOR SHALL MAKE -,,17.2 23.1 24.0
GRAPHIC SCALE
THE REQUIRED NOTIFICATION TO DIG SAFE, (1-800-344-7233) AND 20.3 0.6 22.2
APPROPRIATE WATER DISTRICT TO DETERMINE UTILITY LOCATIONS. 6-33"al)#
x 0 20 40
.8. SET NOW M[ 23.0
15.4 SSING C # 64 Fj 4. M Vj M fSY )?0"
-fill 13.8 STK. SET
x 2,0 2 x 17. n_D C.8, FND,
QJ
20.3 ,
4s
18.1
\G .
Lor 140
18.8 (0.,
Ok
BENCHMARK EL. 24.81'
6.
TOP OF SPINDLE
X ,19.7 j \401 x 21.1
/01
15 SEE D. E.O. E. PERMIT #SE3-3103 FOR DEACON ASSOCIATES,
19.5
21.6 1 .3 x*'l 8.2
O
9.7
17.9 !cam
O
50'
7
T 1
P 23.6
4
22.9 5 5' 4)
*s tic ven t
0.)
0.6 9.6
D9 40 /X
6 8 X
, -A 91TIMIN.- 36" MAX.
/01 20.0
x x
4. 4
A 'd 5 2
14.8 18.5
C.B. SET V
.4. A
4
•
16))
co
4v BOX
D8 24. D S e e 5' 4A
.• 4 4' SCH. 40 PERF PVC
T7l �
X-. 3/4 TO 1 1/2ETLAND L01 .5 2 4 4, mum*mmmim�
A.
a 4 t
WASHED STONE
O 22.4 A d_A
4"
TONE 2 2.6 Cjj TOPPED WITH 2" OF PEAS
6,823 sq-ft�l wetland
F17
38,502 sq.ft' upland
0
TOTAL' \ D PLAN OF
40 SECTION
45,32 S�F,
5 x 23.9 .22.8
1.04 Ac,
14. NO SCALE
NO SCALE
22.6
0
0
x 22.6
7 21.8
21.8 , - COVERS LOCATED TO WITHIN
G.x 12.8 ✓ 21.7 21.5 6" OF F. ALL COMPONENTS LOCATED IN POTENTIAL TEST HOLE
_139 JLJVJ
120.4 1
'LOT - - - VEHICLE TRAFFIC AREAS OR BURIED 4 FEET
ELEV.- 23.0 OR GREATER SHALL BE H-20 LOAD CAPACITY, P-8575
x 18.0
F.G.
x 10.1// TOP OF 22'± CAPE ISLANDS ENGINEERING
12.1 0
FOUNDATION
9/28/95
X 10.2 14. .4 F.G. >=22'±
D4 X �' INV. = 20.0 PIT 2
F.G. 20*.+
x 11.4 j 4
y.
DIAM
x 10.0 15001GAL. Ail T LEVEL 0 ELEV. 23.6
x/ INV. -
0 19.8 �7/ 7
INV. DIST.
x 15.0 • SEPTIC TANK 19.6 INV. 19.4 BOX -z-.- LOAM A 1 OYR. 4/4
40
Vx� x 11�3_H I TOP ELEV. 18.6 7=--
6" CRUSHED INV. 9.2 12"
............ ... .....
'o-00, . ....m-4- STONE BASE INV. 17.6 LOAMY SAND 8 10YR. 6/6
Ci N' BASEMENT FL. EL. 1515 MIN.
Ag 4 z) 10.3 0 0 Q
0
0 N
Az 6 BOTTOM ELEV.16.6 MEDIUM C2
ri
SAND
CP
rTi
x 12.3 _ �' PROF ILE -48" PERK TEST
ADJUSTED GROUND WATER EL. 11.6'
NO SCALE MEDIUM C2
(,5 0
2.8' CORRECTION SAND
10.6 V EL. 8.8' WATER OBSERVED LOT 140
D2
EL. 8.8 -104" OBSERVED WATER PIT #1
/�j -120" NO WATER EL. = 13.6
i D41 SITE PLAN OF LOT 139
DESIGN DATA——
7
X
SINGLE FAMILY- 4 BEDROOMS
1915
WITH GARBAGE GRINDER L*C*C* 5725-46
IN
DAILY FLOW = 110 X 4 = 440 G.P.D.
(OSTERVILLE & MARSTONS MILLS)
SEPTIC TANK = 440 X 200% - 880 G.P.D.
USE 1500GAL.TWO COMPARTMENT SEPTIC TANK
X 11.3
COMPARTMENT ONE 440 X 2' = 880 'G.P.D. MIN. BA k N S' TA B LE MASS .
COMPARTMENT TWO 440 X 1 = 440 G.P.D. MIN.
FOR
CLUSTER SUBDIVISION I CERTIFY THAT THE PROPOSED FOUNDATION
PLAN DATED JANUARY 28,1988 LEACHING FIELD DESIGN SHOWN HEREON COMPLIES WITH THE SIDELINE NORM & GALL LAPRADE
TOTAL ACRES 27.26 ALL PIPES TO BE SCHEDULE 40 PVC PERFORATED AND SETBACK REQUIREMENTS OF THE TOWN SCALE: 1, 20 20' DATE: JAN. 5, 1999
TOTAL NUMBER OF LOTS m 12 USE 3 - 4" DISTRIBUTION LINES IN AN BARNSTABLE ZONING ORDINANCE SECTION 3-"1 .7 REV: FEB. 1 1 L 1, 1999 REV: FEB. 18, 1999
4 ORIGINAL LOTS (116-119) 18'X 50' WASHED STONE FIELD Of A4 (OPEN SPACE RESIDENTIAL DEVELOPEMENT)
8 REVISED LOTS (133-140) AS SHOWN AND IS LOCATED WITHIN FLOOD ZONE C. REV: FEB. 23, 1999 ,
AVERAGE AREA PER LOT = 2.27 ACRES SYSTEM IS WITHIN 250' OF A RESOURCE AREA
us BAXTER & NYE INC.
THEREFORE NO SIDEWALL AREA IS ALLOWED o. 29374 STEP:PLAN APPROVED BY PLANNING BOARD 9-26-94 -!EN'
DATE: s+-61 cl REGISTERED LAND SURVEYORS
A
C.B. FNID. ELEVATIONS ARE BASED ON N.G.V.D. 440 G.P.D./.74 + 50% = 892 S.F, OF BOTTOM AREA REQUIRED 157 -CIVIL ENGINEERS
USE 18'X 50'= 900 S.F. AREA PROVIDED L
OSTERVILLE, MASS,
CLASS 1 SOIL PERCOLATION RATE 11" IN 2 MIN. OR LESS
--- ------------
9,
FLOOD ZONE LINE IS BASED ON 11",
FLOOD INSURANCE RATE MAP
COMMUNITY-PANEL NUMBER 250001 0018 D XT R & NYE INC.
REVISED: JULY 2, 1992:
#96093139
#98135