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HomeMy WebLinkAbout0012 FIRE STATION ROAD - Health 12 FIRE STATION R� A=118-006 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Fire Station Road Property Address Joseph Busk Owner Owner's Name information is required for Osterville Ma. 02655 9/18/2008 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. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: W only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name ~ P.O.Box 763 Company Address . Centerville Ma. 02632 rerun Cityrown State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification r I certify that I have personally inspected the sewage disposal system.at this address and thatNe i+ information reported below is true, accurate and complete as of the time of the inspection. The'Insae tion was performed based on my training and experience in the proper function and ma i tenancer of on site sewage disposal systems. I am a DEP approved system inspector pursuant td--dection jG5.340.pf Title 5(310 CMR 15.000).The system: cr) ® Passes ❑ Conditionally Passes ❑ Fa's - : ❑ Needs Further Evaluation by the Local Approving Authority cn " V l� 9/18/2008 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 1 0,000 gpd or greater, the inspector,and the system owner shall submit the . report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 1 of 2 I - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 12 Fire Station Road Property Address P Joseph Busk Owner Owner's Name information is required for Osterville Ma. 02655 9/18/2008 , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ,Inspection Summary: Check A,B,C,ID or E/always complete all of Section D A) System Passes: -Z 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 spetic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass'section need to be replaced or repaired. The system, upon completion of the replacement or repair,'as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank its less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 i Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments 12 Fire Station Road Property Address Joseph Busk Owner Owner's Name information is required for Osterville Ma. 02655 9/18/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally.Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken•or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will, pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): - distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):- ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection'if(with approval of the Board of Health): ❑ ' broken pipe(s)are replaced ❑ 'Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain.below): C) Further Evaluation is Required by they Board of Health: ❑ Conditions exist which require further evaluation'by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 12 Fire Station Road Property Address Joseph Busk Owner Owner's Name information is required for Osterville Ma. 02655 9/18/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool r ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Fire Station Road Property Address Joseph Busk Owner Owner's Name information is required for Osterville Ma. 02655 . . . 9/18/2008 ' every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply"or tributary to a surface water supply. ❑ Z 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 EJ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or.operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 5 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Fire Station Road Property Address Joseph Busk Owner Owner's Name information is required for Osterville Ma. 02655 9/18/2008 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 ❑ 0 Were any ofthe system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® El this large volumes of water been introduced to the system recently or as part of this inspection? I I ® ElWere 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? i Z ❑ Was the site inspected for signs of break out? 0 ❑ 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. El ® Determined in the field (if any of the failure criteria related to Part C.is at issue approximation of distance is unacceptable) [310 CMR-15.302(5)] D. System-Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts Title 5 Official. Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 12 Fire Station Road Property Address Joseph Busk . Owner Owner's Name information is required for Osterville Ma. 02655 9/18/2008 every page. City/Town State Zip Code Date"of Inspection D. System Information Description: System consists of 1500 gallon septlic tank.1-D-Box and 2-500 gallon leaching chambers. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?.[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2007:195,000 g ( y 9 (gP ))` 2007:195,000 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 9/18/2008 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203); Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Fire Station Road Property Address Joseph Busk Owner Owner's Name information is required for Osterville Ma. 02655 9/18/2008 every page.. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): e General Information Pumping Records: Source of information: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ® Yes ❑ No If yes,volume pumped: 1500 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system t ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any ❑ Innovative/Alternative technology. Attach'a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 12 Fire Station Road Property Address• Joseph Busk Owner Owner's Name information is required for Osterville Ma. 02655 9/18/2008 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 in 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 12" Depth below grade:" feet- , Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance-from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.). Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): 16" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass El polyethylene El other(explain). If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon H2O Sludge depth: 0 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G1,y ,•''V 12 Fire Station Road Property Address Joseph Busk Owner Owner's Name information is required for Osterville Ma. 02655 9/18/2008 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 NA Scum thickness 0 Distance from top of scum to top of outlet tee,or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? tank pumped at inspection 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 two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): J Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 L_ Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 12 Fire Station Road Property Address Joseph Busk ` Owner Owner's Name information is required for Osterville Mo. 02655 9/18/2008 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 12 Fire Station Road Property Address Joseph Busk Owner Owner's Name information is required for Osterville Ma. ., 02655 9/18/2008 every page. City/Town State ` Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert No Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box is level.Box has two outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage into or out of box. 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.): y Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments M ,•' 12 Fire Station Road Property Address Joseph Busk Owner Owner's Name information is required for Osterville Ma. 02655 9/18/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® 2-500 LC leaching chambers number: ❑ leaching galleries number: leaching trenches. number, length: ❑ 9 9 ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soif.No signs of hydraulic failure.Stain line was 13"from invert at time of inspection. r Cesspools (cesspool must be pumped as part,of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No - t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M ,•'y 12 Fire Station Road Property Address Joseph Busk Owner Owner's Name information is Osterville Ma. 02655 9/18/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . I Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids -- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 Map Page 1 of 2 Town of Barnstable Geograp-hic Information System + Map Size Zoom Out� R In Parcel Viewer Custom Ma Abutters �.� . �. �. p JJJJJJ % fi S x M1 f V 'f J -y y y hD ( 15 1 - 5 ' 20 Feet W Set Scale 1""= 20 Aerial Photos I MAP DISCLAIMER ' (`nnirinhT onn S_7nnu.T--of `AAA All rinhf.rotor,,, http://www.tOwn.bamstable.ma.us/afcims/appgeoapp/map.aspx?propertyID=118006&map... 9/23/2008 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 12 Fire Station Road Property Address Joseph Busk Owner Owner's Name information is required for Osterville Ma. 02655 9/18/2008 every page. CitylTown State Zip Code Date of Inspection D. System Information (cone:) Site Exam: . ❑ Check Slope ® Surface water . ® Check cellar ® Shallow wells Estimated depth to high ground water: Bottom of LP 13' feet Please indicate all methods used to determine the high ground water.elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ®: Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of groundwater elevations. _ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection,Form:Subsurface Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 12 Fire Station Road Property Address Joseph Busk Owner Owner's Name information is required for Osterville Ma. 02655 9/18/2008 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System.Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file r f t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS -. hk 's is ,�.. . . • t a;;EXEP 'TIVE OFFICE OF ENVIRONMENTAL AFFAIRS LT DEPARTMENT,OF ENVIRONMENTAL PROTECTION . t a TITLE 5 OFFICIAL INSPECTION.FORM.-.NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: /2 �i S` avw wuoQ p , / 44A 02,Gs5- Owner's Name: M 4 uiH RFC � I Owner'sAddress:......../? I Date of Inspection: �-�S-o JAN 2 (UU/ I Name of Inspector: (please print) Oh., TOWN or bHDEv T E HEALTH CENT. ,F Company Name•. �Jo4 A?a//o lgg,c A, oz 5.1rvi-+. Mailing Addresst� /82 57 Mz is /W.�0�6 y I< Telephone Number: '5"o8 - 1/2F -777!? "- CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is,true,accurate and.complete as of.the time.of"the inspec4on.The inspection was performed based on my training and experience in the proper function and maintenance oaf on site sewage disposal systems.I am a DEP, approved system inspector pursuant to Section 15.340 of Trtle;S(310 CMR 15.000). The system: (i Passes t - Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails t Inspector's Signature: Date: The system inspector shall su mit 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 y authority. , .``.4.n, FJ­A' } E w.:'!v,C °,»�' f,w,r•:' e', " y `.I� . ,A *' Notes and Comments **r*'*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. f Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM- R'VOL ARYAASSESSMFNTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR1V-"=,'-;1* PART A CERTIFICATION(continued) ' * r�. ` Property Address: nrivvw to /Y/A Owner: /�lG�i�,,o �v�.�kl.• Date of Inspection: /-26-O-� Inspection Summary: Check A,B,C,D or E/ALWAYS complete"all A'Seftlom.D, A. System Passes: f-- 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: r. 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 failtim is immineriL 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 pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more thad 4 times a ear due to broken or obstructed pipe(s).The system will Y 9 P P g Y P P 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, 5 CERTIFICATION;(continued)'. Property Address: 1 /�/rr S�ayio., Rcri� Owner: Ara r k4., R Date of Inspection: C. Further Evaluation is Required by the Board of Health. Conditions exist which require fiuther 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,;.'.s' _ 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,isr,within.100 feet of a surface.water supply or tributary to a surface.water supply: t„ J qa p ,The system has a septic tank and SAS and the SAS is'within a.Zone l of a public'water supply. The system has a septic tank and SAS and the SAS is:within 50 efeet of a private water supply well...' _::The system has a septic tank and SAS and the SAS'isJess than 100 feet but-50 feet or'more from a' e private water.supply well".Method.used to determine distance r , "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 Wequal to or less than 5 ppm,,provided that no other z , failure criteria are triggered.A copy of the analysis must be attached to this form. "'lie Y 3. Other: - W ', - -.:« � .•a:',. F'.1=.: ,... rc.: :...,.,. _.. .. ,,. ., a .. ' F �: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT,FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPO§ SYSTEM:INSFEGTIONYORM PART.A q t CERTIFICATION. coattinued) # { 7; .H o u 0 Property Address.` ` //o Owner: o /tern n Date of Inspection: 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'wateis 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 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. _ T/ 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'' O'feet'fi-om xprivate water supply well with no acceptable water quality analysis: [This systein'passes if thew +water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution fromthat facility and the presence of ammonia nitrogen and nitrate'nitrogen Is equal to or less'thati 5'ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] /yo (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 Systems: To be considered a large system the system must serve a facility with a design no*of.10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of thefollowing: (The following criteria apply to large systems in addition to the aiiiria 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 44 " ' e owner or operator of an large system considered a yes m Section D above the large.system has failed.The p y g y 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 11 .: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACESEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART•B c . :-CHECKLIST Property Address: A2 Owner: AAx fH,o )5 k Date of Inspection: 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 L 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? r/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.? r ✓_ Were all system components,excluding the SAS,located on site? _v _ 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 jSAS)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 15.302(3)(b)] 5 , Page 6 of 11 .. OFFICIAL — C INSPECTION..FORM .NOT FOR .OI,L�NTAI�ASSESSMENTS , SUBSURFACE-SEWAGE DISPOSAL.SYSTEM INSPECTION FORM.:,",.., ... . 'PART.0 SYSTEIV INFORMATION Property Address: /1� `r�So+•</�aa+� nip gt>J'� tirr•,s'1 Owner:-_/Vux •�� ��•,k/,:� Date of Inspection: /— 2S Oa _..-......._ ;;.,1Y.., ��✓.`.`" FLOW CONDITIONS RESIDENTIAL (design): -•3 Number of bedrooms(actual):. �1 Number of bedrooms desi , DESIGN flow based on 310 CMR 15.203(for example:•l 10'gpd z Itof bedrooms) 30 Number of current residents: . Does residence have a garbage grinder(yes or no):XA1 Is laundry on a separate sewage system(yes or no): [if yes separate,inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no): Nn c.., Water meter readings,if available(last 2 years usage(gpd)). 2 6,=�`Moy. 2 pp y,� . Sump Pump(yes or no):�/o Last date of occupancy: o N l COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgR;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: Was system pumped as part of the inspection(yes or no):—p If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: 7. 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.Att=.h`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: g-2O—00 Were sewage odors detected when arriving at the site(yes or no): 6 Page 7 of 1 I 1a :OFFICIAL INSPECTION FORM='NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE'DISPOSALwSYSTEM INSPECTION'FORM SYSTEM INFORMATION(continued) Property Address: �� �rt S �ia". eaal. ��trvillo NA Owner: Date of Inspection: . BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast ii `' 40�Ion PVC--,-, ' _`other(explain): Distance from private water.supply well or.s me:" Comments(on condition of joints,venting,evidence of leakage,etc.): . SEPTIC TANK:_(locate on site plan) Depth below grade: /6 Material of construction:._concrete metal_fiberglass Uolyethylene..... .. 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: J015' X 6 :t'f•:.1+ ! !.rff j r ..% +, :i�: tr 1 ut.I:i" li Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: .3.y'� ` ' �•:', i r :n r , Scumthlckness: r ©':'i ':.i :<.'St>i3C ij5'iA�f �':i1Ti .f�l�?ii.liaEU�.ti. tl. i}ls� f�F71. '•lIa , i' ? tT ', r.r:� Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or.baffle: —. How were dimensions determined: place Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): �qnk /J Zlf/L( . .. i f•,rr r,?,,•I1 1 `����t'Ii�"i.'�`N fa g .!;�t1.,. GREASE TRAP:_(locate onsite plan).�, i' t q.riu n i s:rest•"•�,�oa`3,°u )Etna,,. .; Depth below grade:....,........ Material of construction:_concrete=metal_fiberglass polyethylene_other (explain). ' Dimensions: , .. r 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: N Date of last pumping z Comments(on pumping recommendations;inlet and.'outlet tee or baffle`condition,structural integrity,liquid levels ' ` as related to outlet invert,evidence of leakage,etc.) Page 8 of I 1 ;.,OFFICIAL-INSPECTION.FORM.-;NOT- DR V4EUNTARY,ASSESSMENTS I.SUBSURFACE SEWAGE DISPQSAI .SYSTEM.INSEECTION.FORM:. ' ..PART'.0 - `y.j SYSTEM INFORMATION(continued) 2 �rla7`' Property Address: � �S� �o� /pol�rf . Owner: Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumped at time of fi*ped*wnXSdtatean 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:: /9 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.): to-a R plan) PUMP CHAMBE •. (loc ate on site P .. Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of'ptmtps and appurtenances,etc.k ; 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY AS SESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 12 �C04re- vi%l,0 Nh, Owner: irkaak&, Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: V leaching chambers,number. 2 Soa�11/, leaching galleries,number: ; leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,-number. innovadve/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): w0 Jot X 2S�Lo.,y yc 3 �-e SizP oT �acr��fy CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: F 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: (locate on site plan) y Materials of construction: 'Dimensions: Depth of solids. _r Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc): L t i 9 . Page 10 of l l , OFFICIAL INSPECTION FORM NO' -FOR Y "MAY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SY4T61 INSPECTION FORM PART.0 . SYSTEM INFORMATION(continued) Property Address:�� ors 7df o,, /Qc�d Osl�rvll.v 469 Owner: Date of Inspection: �25-02 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. Lf 6 � /ram., cov�I•f � - .Z o O o O n�le�,,y oti t 3 2 .. 1 ' 2 2/ , 3S , y $ / 6-6 / 10. Page 11 of 11 OFFICIAL INSPECTION FORM.—NOT.FOR VOLUNTARY ASSESSMENTS ;'SUBS,URFACIi SWAGE DISPOSAL SYSTEM INSPECTION FORM r! PART C` SYSTEM INFORMATION(continued) Property Address: iI arc ,SZfoi, �oa� _Owner. �Llaxi:,v' r4H ,... Date of Inspection: TE EXAM r Sloe Surface water " Check cellar Shallow wells ' Estimated depth to ground water 27 ' 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: 11�ti ds . Checked with local excavators,installers-'(attach documentation) Accessed USGS database-explain: M.:as af- 7o%,,,"/ /I You must describe how you established the high ground water elevation: r ow �, 35-$ j 7, v .ors. SAS, Fli ie,.., o. + 2�•`/, . rorsw 7fir 1. •�. Disr�c .Behvte., orJo;•. 5<75 is 13. •r II 1 TOWN OF BARNSTABLE LOCATION_tot ICie SEWAGE # o219p4'/7( VII.LAGE_ I�S�anr-�`�!1 ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SC. A lfp SEPTIC TANK CAPACITY / L�O S LEACHING FACILITY: (hype) -7- So vs (size) y✓3(a S �Xa 'D NO.OF BEDROOMS_ � BUILDER OR OWNER j �d _g. r _ ! PERMITDATE: =//—,�000 COMPLIANCE DATE: i 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) Edge of Wetland and.Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Feet _ TOWN OF B ,�/ ARNSTABLE g 004 E►"' LOCATION f rE' 24f%_gS SEWAGE # o2Vp0'170 VILLAGE �S�e4��lf ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 00,, /f0 SEPTIC TANK CAPACITY LEACHING FACIL=: (type) (size) / �141y(a S �X o7,D NO.OF BEDROOMS BUILDER OR OWNER 9IMr PERMITDATE: ACOMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) Feet Furnished by { o� oZ 3 .; a3 Z A No. Y4f `�` Fee — n THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Q� PUBLIC HEALTH DIVISION — TOWN OF BARNSTABLE, MASSACHUSETTS s 01ppittatton for Mtzpool *pztem Con5tructton Vermtt Application for a Permit to Construct( )Repair( aupgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. ` n` Owner's Name,yA�ddress and Tel N Assessor's Map/Parcel Install Name,Address,and Tel.No. Designer's Name,Address and Tel.No. STEPHEN J. DOYLE & ASSOC. �✓ 42 Canterbury Lane East Falmouth, MA 0253E Type ofB ' ing: Te ep one: 508 540-2534 wel m No.of Bedrooms Lot Size i Z Z�� sq.ft. Garbage Grinder( ) er Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 33® gallons per day. Calculated daily flow gallons. Plan Date lq\^y ra ,pop Number of sheets 1 Revision Date _ Title !Strrt Z \A m 1 Size of Septic Tank CsAuls Typee of S.A.S. Description of Soil 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 itle 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has be issu d t ' Board of Hea Sienehi Date e� Application Approved by .- Date Application Disapproved for the following reasons Permit No. Date Issued --------------------------------------- No. f Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS �1 3pphratton for .at.5po5ml *pgtem/Comaructton Vermtt Application for a Permit to Construct( )Repair( Upgrade.( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No ,p Assessor'sMap/Parcel 00 Install Name,Address,and Tel.No. Designer's Name,p�dress and Tel.No. STEPHEN J. DOYLE & ASSOC. _42 Canterbury Lane r East Falmouth, MA 02536 Type ofBuil ing: r lep one: 40-2534 wellin No.of Bedrooms 3 Lot Size 174,!.YA sq.ft. Garbage Grinder( ) er Type of Building No. of Persons 'Showers( ) Cafeteria( ) Other Fixtures Design Flow 33 O gallons per day. Calculated daily flow gallons. Plan Date 1*-.1,ar7t_4a 1q :2"pn Number of sheets N Revision Date T Title Size of Septic Tank Type of S.A.S. z oo Description of Soil Nature of Repairs or Alterations(Answer when applicable) ry 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 itle 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has bee RR tssu d t ' Board of Hea SigneS Date Application Approved by _ Date �' �—' x � Application Disapproved for the following reasons Permit No. "' Date Issued THE COMMONWEALTH.OF MASSACHUSETTS BARNSTABLE, MASS ACKUSETTS Certtftca -ef Pol­ omphance " THIS IS TO CERTIFY, that the On-site Sef/age Disposal System Constructed( )Repaired ( )Upgraded— Abandoned-( ,lby n^a/ e. at ft a[ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit ' ,1 dated I W ,,- Installer Designer The issuance of e t shall of a construed as a guarantee that the s to li'f n on ass psi nec{ Date p % g Inspector g V% UI,I i ���" ✓ �C 1W V e.—�--,-- ..e /--------------------- ®._._------- No V'�i��—/ LY Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Itopogal *pgtem ConfStructton Vermtt Permission is hereby granted to Cons. ct( )Repair( )Upgrade( )Abandon ) System located at and as described in the above Ipplication for_Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this peppit. Date: � Approved by r L , :v INDOW KEY LEGEND =4I U� z ------------------------- a �.v IN OO:V TYPES LEGEND . I ......... POO"PLAN m OUPOI:. _______________________ I I .-.-.-.-.--- .-.-.-.-.-.-.I .-.- I I - I ( I I _ __ __ _ o ------- --------------- !/5/� r Z wrr� --- _._._. ----------- ----_-- --------------- ----- , i i I i i Public Heal+h Division Town of Barnstable SECOND PO Box 534 "LOOP a Poo" Hyannis, Massachusetts 02601 ;eow .LAMS Fax(508)775-3344 R Phone(508) 790-6265 A2.2 na.n uu xv vr.n mum Y .uuevn.•w n. 1 a r.�. °W'631v1°°6SV IY°O 109 NVAI 30N301S3U RMINVUd-41-1 NOLLIOOV E<14<]44 o iil!ii ei� Il it as s a t ass t tiiiit o iw I1 IE I1 o �iltiilil I' �` `;` � a I CD i co sn 'CS !.l111 ch " 6 v ch p O N Lip ;I � t` . =1' E c`o M O CO Ln X N cc �i C) CC LL- O_ ti y 3 c t'c .----- 1 if -� --::_�_:-_- • 'je 0 F� • \N� i7y41 / .w., ❑ E I.<;I i (_) I.:i. E Al: a . .::.... _.......................... Town of Barnstable P tt Department of Health,Safety,and Environmental Services �'THE% Public Health Division Date O-z-az -tea �* 367 Main Street,Hyannis MA 02601 a►waarABLF, Mass. '°rEn3� Date Scheduled O� Time Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By; S �� Witnessed By: u, NaJ t'-** LOCATIOlt1 & ENERAL;INFORMATION Location Address Owner's Name Q Address �TEPHEN J. DOYLE & ASSOC. Assessor's Map/Parcel: 1 u/ (o Engineer's Name 2 Canterbur g Y Lane East Falmouth NEW CONSTRUCTION REPAIR Telephone#. Telephone: ' MA 025 6 Land Use t�fs _y,�-1 A-1- Slopes(%) yay, I'D t0 Surface Stones - b i• l t Distances from: Open Water Body 15 ft- Possible Wet Area 15-0 ft Drinking Water Well 1•S-b ft -Drainage Way \ p I It Property Line 1,D I ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) t .t �1 -��-` yct i� qas— Parent material(geologic) I;L3 Depth to Bedrock V.�-/A Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face t� - Estimated Seasonal High Groundwater L �� ..:.: ,.: TEIA 't11�i FOR SEASONAL; H. Method Used: ID-i3sl':xW rirtQ" Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well#__._._ . .Reading Date: :__ Index Well level....—.--__ Adj.factor __ Adj.Groundwater Level PER OLA.TI0 'TEST pate o Observation Hole# z Time at 9" Depth of Perc `50 u ''�( u - Time at 6"' Start Pre-soak Time @ 11.00 R?to Time(9"-6") End Pre-soak �t'.\J� j IAI XA-V-,LJ�a- 7 RateMin./inch GZ ZZ tiri� Zee ( �atVs Site Suitability Assessment: Site Passed "/1 Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant DEEP OBSEItY.ATI011 DOLE Lt7 Mole##, L�` Depth from Soil Horizon Soii Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. C n i tent %Gravel 7l�o / e^t, G.o rStt=.5 ............. ......... .................................. .VEEP OBSERVATION HOLE L+O Hole# ....... Depth from Soil Horizon Soil Texture Soil Color Soil ther Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.°o ravel .ay, Go Zo-132t C Z'51 -(A, ..... 1=��r SNwaD ...... HE..... ...EI' (IUS....E.... ATIUNIOIE LOC ...I................. Foie#' ........... ......... .Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.°o ravel L_ BEEP OBSERVATION HOLE LC);iG Hoxc# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,° Gravel) Flood Insurance Rate Mao: Above 500 year flood boundary No_ Yes Within 500 year boundary No_ Yes Within 100 year flood boundary No_ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? pzT-T5� If not,what is the depth of naturally occurring pervious material? 1. Certification I certifythat on 3 � date I have passed the soil evaluator examination approved b the (date) P pp Y Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,expertise and experience described in 310 CMR 15.017. 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CORSE GRAVEL • - CORSE GRAVEL (NO FINES) d v (NO FINES) v v 2x4 EXPANDED 2x4 £XPANDED 4" 0 PERP. DRAIN ;K£Y POLYSTYRENE 4° 6 PERF. DRAIN _ °KEY POLYSTYRENE REVISIONS PIPE. PERF FACING INSUL BO- PIPE. PERF FACING BD- ON — MIN. R-5 ON N! MIN.R 5 FILL4° STUCT. MIN 4' STUCT. �EgEDARCjy� 20' FILL FILTER FABRIC 2 0 10°x20' CONT. FILTER FABRIC 10°x20" CONT. ? CONC. FTG CONC. FTG W. ABtP E . UNDISTURBED SOILS E UNDISTURBED SOIL � or TYP. FDN DTL W/ KNEEll LL TYP. 10 C0NC. FOUNDAT1ON �UALL 4 SCALE I„=1, 01_0„ SCALE I„_I,_0„ menu" rt� =est�4aL�asxq� �a�eon�e5a�s3a . .' h6jA SZT?,4A7 esd4as��afehime"nfsi eotn�;s. x e 3-1 3/4xll 1/8 CONT. LVL OUTSIDE GALLERY 2-5/8' 01 THRU- 4x6x4 -BOLTS l° GA GL. BLOCK 2" DEPRESSION . BUSK RESIDENCE l 1/2'Hx10'Lxl/4'T FOR TILE TILE FLR'G SIDE PLATES OWNER WELDED To- 12 FIRE STATION ROAD I/2'Tx6 1/2'Wx10"L I/2' BACKER PLATE 4tl1 .6 PLYWDOJGBD OSTERVILLE, MA 1 -3' NOM LALLY SUBFLR PROJECT COL CONC. FILLED EXTENDED a FDN ° 1 3/4x9 1/2 I i 2-5/e° (d EXP. BOLTS WALL ® 14' O.C. FOUNDATION DETAILS 1 TO FTG (TYP.) 'Tx5'WxI0'L v. DRAWING TITLE BASE PLATE JOB NO D(:DETAIL LALLY COLS (TYP.) CTION 3 GALLERY FLR DATE 1 OCT. 2004 4 2 DWN MM CKD SCALE i I/2"=1'-0" G)�S CALE I"=1'-0" SCALE AS NOTED DRAWING NO A a� NOTE:... 0 MW OV=T M y coucme. W,p WPC fib' f' g cApizTv ounfT c=t s1P ------------------- -- _;X 1 . r<ec ? -u�r -- - PrHDPW Mt—f ct.�*U tT 0 ��fAC�hfl�b�l fLl�t{T - w DA � ta,.jv rr _ W.BARNSTABLE . MA I 7< MP` _ 1 , Elp a { �I ments 157 boylstan street hasten.massachusetts 02130 ji t 6I7 522 7447 Isola rz®arc himenls.com PERMIT SET NOT FOR CONSTRUCTION I � I BUSK RESIDENCE owNBN 12. FIRESTATION ROAD OSTERVILLE, MA AOJId GT BASEMENT ELECTRICAL PLAN D1Aw'INo TITLE 0 . ,Do ND308 1 1 OCTOBER 2004 Algr, d 1/4rr 1, Orr SCALE DNAw INo NV _ TIL!_--_fib - � - rxirFrb ►�'',� ��I. C�pUl�a P,aULt'f`zot�r� 1.: v r l , Sl i 1 ... _ - Prco� IV ty)UR.WAY — rl` lzf \t = actA e�� l '- 71,1 ---- -- ` EO PN L"SCS�j it W. 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'gyp 'a b _ i y. $R$�fS1j$ "� Gd A .a a �rc, • r n D D D D D s ADDITION I® the ]FY�.I$�dkLIN RESIDENCE � 'DIVAN BEREZNIICKI ASSPCIA'I'ES,INC. Fa Q ,RCHITECTed PLANNERS `• C:e1 y > 0 Q 0 O - 1009 MAIN STREET 9 WENDELL STREET,CAMBRIDGE,MA 08U8 F7 © $ R 08TBRVILLE.MA88ACHU8ETT8 TEL:(619)3S4-SI88 FAR:(617)860-9764 t - ' a� K�� , t,r z z r 4 » • e. , I W�� TAll _R� 0 _�_L VI� IV, 7 , Sl • TOP FOUND. EL 3z.5 •;• /v • , , ' _ ,��� - �_ ►� � _ � Reference Deed.• `�-- --wA>Ert 1pOMT COMER -:• INV. EL 23'D FLOW LINE � TOTAL L ENSTH OF TRENCH = z-s 2752/115 14" INV. EL. ��r•7. '� �° ' TPENCH SEC TI dN Reference Plan: l(9 TAila. g8� ltOUiD DEPTH Sid 'b 171/111 Op' 04 INV EL. 1`f.�' q 4" DIAM. 12 MIN. INV. El. _ {NV. EL. vco. 1co.-3 4 .oy C� G_1 1 r-� © q © © o o asp: s►d� o 3" OF 1/8"-1 2" ZOnln�, District: R(,Y ----------•---- - ��. �4••3 � 4 as ,e•• . o•.. o .c•' g JV SHED. PEAS TONE _ w •• 5 314" - 1-J12" WASHED °;a• Overlay District: HT PRECAST REINFORCED CONCRETE 1500 GALLON PRECAST REINFORCED CONCRETE SEPTIC TANK DISTRIBUTION BOX �`• a'3 R r= CRUSHED STONE :• o a: ©y G_I �' �� "50 0 GALLON DP YXEL L S " s z Building Setback.• MINIMUM CONSTRUCTION MATERIALS PER 310CMR 15.226(2) INSTALL ON A LEVEL BASE TRENCH WIDTH= �' FTOn t — 20 TEES SHALL BE CONSTRUCTED OF SCHEDULE 40 PVC AND MINIMUM WALL THICKNESS = 2" SHALL EXTEND A MINIMUM OF 6" ABOVE THE FLOW LINE NUYISER OF TRENCHES I OF THE SEPTIC TANK AND BE ON THE CENTERLINE OF THE MINIMUM INSIDE DIMENSION 12" NUMSER OF DRYWEL L S 7- Side & Rear — 1 D' SEPTIC TANK.LOCATED DIRECTLY UNDER THE CLEAN-OUT MANHOLE OUTLET INVERTS SHALL BE EQUAL TO EACH 0 ER AND AT 20 MINIMUM BELOW INLET INVERT. Assessors Map: � THE INLET PIPE ELEVATION SHALL BE NO LESS THAN 2" NOR MORE THAN 3 ABOVE THE INVERT ELEVATION OF THE THE DISTRIBUTION LINES FROM THE DISTRIBUTION BOX 118/6 OUTLET PIPE. SHALL ALL HAVE EQUAL INVERTS AS DETERMINED BY FLOODING THE DISTRIBUTION BOX TO THE HEIGHT OF THE DISTRIBUTION SEPTIC TANK SHALL BE INSTALLED LEVEL LINE INVERT AFTER ALL LINES HAVE BEEN SEALED IN PLACE.LEVELAND TRUE TO GRADE INVERT ADJUSTMENTS SHALL BE MADE BY FILLING WAIN DURABLE «°� ON a LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY r = Sreet Address• #12 Fire station road COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED STONE AND NOI RECO STRUC 1 O THE AI. PERMANENTLY INVERTS TO THE LINE OR RECONSTRUCTING THE ONES UNTIL ALL NVERTS ARE OF HAS KEN PLACED TO ENSURE STABILITY AND TO PREVENT , EQUAL ELEVATION. 5EITUNG. Ia , FEMA Da te: SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9". '' ,• j. ' „ „ . ,. ., Locus Lies in Zone C THREE 2W MANHOLES WITH READILY REMOVABLE IMPERMEABLE COVERS OF DURABLE MATERIAL SMALL BE PROVIDED WITH ACCESS ' k• i Panel 250001 0016 D Rev.• Jul 2, 1992 PORTS BEING PLACED AT THE CENTER AND OVER THE INLET AND ,d `y• "` y OUTLET TEES. THE OUTLET TEE SHALL BE.EQUIPPED WITH 'GAS BAFFLE. ^. �.y :�s x-„ '•-{•."� y Note: Pump & Fill Existing Cesspool yr 4 �• • IYith Clean Course Sand. Existing Sidewalk U. S.`G. S LOCUS : MAP GENERAL CONSTRUCTION NOTES 1. ALL WORKMANSHIP AN MATERIALS SHALL CONFORM TO D.E.P. TITLE 5 ' 76'6 cesspool AND THE TOWN OF RULES AND REGULATIONS FOR Proposed S.A.S. Expansion Area 30 32 THE SUBSURFACE DISPOSAL OF SEWAGE. Proposed SAS. Drywell Trench �� PARCEL 6' 22.3 :� I 2., AT LEAST ONE ACCESS PORT OVER TANK TEES SHALL BE-ACCESSIBLE \ 12,274 sq.ft~ I. `d WHITHIN SIX INCHES OF FINISH GRADE WITH ANY REMAINING ACCESS ' , 102.20 PORTS BROUGHT TO WITHIN TWELVE INCHES OF FINISH GRADE. `�20 IN% o� GRAPHIC SCALE . \ "128 �.► N,28' o I 3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF 20 0 10 20 40 e0 WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10' . w 24 Existing 3.1 r OF DRIVES OR PARKING. H-20 LOADING SHALL: BE USED UNDER OR WITHIN .� Dwelling 2 ` 35 ` 6� P d t'o ( IlJ FEET ) 10' OF DRIVES OR PARKING UNLESS NOTED. 34 - 4. THE EXCAVATOR/CONTRACTOR SHALL VERIFY THE LOCATION OF ALL 10 �xSZSTING BUILDING -' _ O ANY EXCAVATION. -No-t'�: Z•• i inch 20 ft. SITE UTILITIES PRIOR T EX 1. ; �••' Existing Curb 5. SEWER PIPES SHALL BE 4" SCHEDULE 40 PVC LAID AT 0.02 SLOPE. S �.s. `S "$�`ow Q`'sr coilc�+ 1 E s�,�g r-Lsv ' -30 PI a z� Vie w 6. ANY MASONRY UNITS USED. TO BRING COVERS TO GRADE SHALL BE - •j3' , ': � �cfl 2e 4���� ' I 32 MORTARED IN PLACE. ; 'i x ;.. 118.65 32.6 ave I 24 P 7. FINISH GRADE SHALL HAVE A MINIMUM SLOPE OF 0A2 FEET PER FOOT. d/b—H20' • . -r , 26 ;, .• 20.0 ` "edge • , 70 187.15 __. << .�, :.• : °• t- ,,: ,` o mad Exist%ng •�: (I Pav�ment� 22 tariK d Y galjori rem°ve r 01 1 be prre ops Jt- t1'u°t ' ; f ex ti¢9 s 18.5 54 ' 20 is SOIL OBSERVATION DATA: -' � to P°r t1p11 ° deno TEST DATE t ed d° " SOIL EVALUATOR •D 6r. B.O.H. AGENT J� •`!•��etu �► ��1L�! JL �_/_3L_L �Y JL " �_C.�t �L �Y JL/ EXCAVATOR ��.;o Go�ycauc�•�nr3 _ DESIGN DATA: PERC/RATE STRUCTURE x�ST. t� y(� p I11T TYPE N0. BEDROOMS GARBAGE DISPOSAL \\-,r �`//TT� DESIGN FLOW `s \o = -s'-3a c ' h�.��w y _LA e0,1R._it �u PREPARED FOR j t..S -A/1-A _3CIIVE; 1Z S 'T•S�I� SEPTIC TANK 3'3o x-�oc��' — b0 L>,St= 15"•OD "Z�{�.�`DiV 1�ZQ 1-040 IjA OF At, i CNG }-iNc LEACHING FACILITY �- -� �Za�► ' k 1 Zo1stER as°Ca N OF,�,� c� j z•s�j �l co G -z,s� 'I f(, _-- -L----- ' - - =- --- STEPHE�r AS SHOWN ' DATES March 14, 2000 N o c WILLIAM $` LlOYL IEBERMAN No, 23971 �A � i�Zl� `1�0 �•�--- 13z.° ____ 1Mo. 37559 Prepared B Stephen J. D yle and By: anterbury Lane, East Falmouth Massachusetts 02536 I ©� u Telephone: 5081540-2534 �•� `lam