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Home My WebLink About0014 FORTES WAY - Health A4 FORTES WAY, OSTERVILLE = 1422 f� I I a r Commonwealth of Massachusetts Title 5 Official- Inspectidn,.Ri . ri Subsurface Sewage Disposal System. Form.-Not for Voluntary Assessments&uc 14 Fortes Way ► €�Y ,!�',; Property Address Jeffery Beggs �0 ,� Owner Owner's Name/ �,. information is , - required for every Osteryille,.,. *r" .rrn f;.�i MA 02655 5-5-21 ' -1 + page. City/Town , ;,:_ a - 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. , F r� 1� t� , > it .. ._. ,• "- -rrs. . .'�. :'y:r°aU„ i!'�+('ts�;+ °fi A. Inspector Information Shawn Mcelroy '°u Name of Inspector.! '€ }LVJ .}F.:.",Ut t1 2rl1"Y 1`fa[... ;€r q(.Sx %Ov. ar,l 4'41.. _ styrl • 1 Upper Cape Septic Seivices Qi.e w �. W. G i c m "t, ". ;e r �Af_:.1 0 F n? Company Name P.O. Box 73 �,�:- n)ftJ:€ Company Address East Falmouth t 5_I ,. a°-�, wi ti.-i t+MA,r o A fit-,1*?02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in fulltcompliance with Section 15.340 of Title 5 (310 CMR 16.000);1 have personally inspected the sewage'dispo'sal'system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and 'the inspection was performed based on my training and ezperierice In the proper function and ` L i ?maintenance'of on-site'sewage disposal systems.After conducting this inspection I have determined that the system: IL1€ x-1`, t'�:'" .=`1 Y t Otpr•I°"e iDjO%'.scan'1), Oil',ti},.v 1,1, 1: ® Passes t I it j • i}n.}`��4K WGF��.'.n� t11�."r€tfl+T-•-3v wl ',• 'a,.' ,€ : -1 2. ,❑-Conditionally PassesF�,� ;r+: .t.}Lt,`� ti..i� J. "; !fte rF ?r a. 1�v1 �� ;rY-.:..'ll ° = t• ,.' ..i•'�`h °4f:"-ia74 ' i"r Ro fit'lnll .3., ❑ Needs,Further,Evaluation by:the,Local Approving Authority ,)fjk ti_ tljtb:,H 4. ❑ Fails € 3I1U19 J i r•°ac ,tE:l�rt3.1''t° M' ' 'I prtf`r <t1 -,, `-pi 1 ;14(" A 3 r iti. U�z rt f7r•.�'� �� ,lbi.,€i1 .r•€{.. f'r{!t 1.10v x I'Mckt,'t}J 5-5-21 'Af-I -nspector's Signature 4 Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection: If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. M Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.17/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 •. Commonwealth of Massachusetts l A _ �; . • k _ ' ' Title 5 Official- Inspecti®nyF®rm' ibi Subsurface Sewage Disposal System Form=Not-for Voluntary Assessments ' e <, s f 14 Fortes Way J Property Address Jeffery Beggs Owner Owner's Name information is required for every Osterville �`' MA 02655 page. City/Town State Zip Code Date of Inspection C. Inspection Summary • f.. 3 .. `e ,M1 t' •,� .l .t�}r.3::jai"7. '.� �' f`. ... . �e'',:'C r i 1:. �' Inspection Summary"' Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure;criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: ` System is in good working order with no sign of failure. t • 2) `System Conditionally Passes: ❑ One or more system components as described in the"ConditionalPass".section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is'replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): t / ? a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 - , Commonwealth of Massachusetts a Title 5 Official InspectionTot-m' " :N Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s •c:,J � 14 Fortes Way Property Address , _ kr Jeffery Beggs , • 1.., Owner Owner's Name information is Osterville , ;+. MA 02655 5-5-21.� ~ required for every page. City/Town State Zip Code Date of Inspection C. Inspection'Summary (cont.) r;;,� - -, ;� ,�- ' 's ,;• 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with. Board of Health approval if pumps/alarms are;repaired I . ' C' _ ,3'. . "1i'�' "� '?T,.,+ A,.��r.sa, f' Is•�if><i ''�}1' :`£. elf", .},It� ` i,i;;, -� - -�t ?• �� i• ,_.,, L~ ,-.d• .. 'fir'#;7...*,I ,�- r+� .iti?'-w; ir v "�, }'1 r17 '•a:ai�: ,-3 ❑ Observation of sewage backup or breakout 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): u ' . . r ' ."�:, -"r :' i_ ,{� _:fir_ f'•t,�` :r. .. :1 k: �"7 ,� `'v� '` " ' �❑ broken pipe(s)°are replaced 'f `` `� " ' +z 2Y`"E]N"' '❑ `ND (Explain below): ❑ '-obstruction is'rerrioved • `' }n'" ': ❑ Y ❑N+� ❑ ND (Explain below): t . ,. 'r❑ �' distribution-box is leveled r,replaced ❑Y ❑h N - El 'ND (Explain below): ' , ' 3_.'(! i,i '•-:lf .•S1i S'3'is' ?.. got r 'It" ',e i:{ rIt :� ' !1 ti r•c• r,? a' iw,.11 .*2A 'If I of ❑ The system required pumping more than 4 times a year due to broken or.obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): 3) Further Evaluation is Required bythe.Board of-Health:;•,, j�� -'f;i ►,a,,;' ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if 'the'46m•is failing to protect public health, safety or the envvironmen4:' ' ` •a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ... " r, . . . „., .' ` V•jPr,� •. +�� ,-'t.e_ '^i? , .jib+�_�zr tn� ; t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 3 of 18, ee,., Commonwealth of Massachusetts , . Title 5 Official Inspection.,Form* hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Fortes Way Property Address Jeffery Beggs Owner Owner's Name information is required for every Osterville MA 02655 5-5-21" page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ti ❑ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: -' t ❑The system has a septic tank and soil,absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. -❑The'system has a septic tank and SAS and.the SAS.is within a Zone,1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water -supply well. ❑The system,has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. sw, c: Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or,,;`No"to eacli of the following four all inspections: Yes NoEl ' ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts ;p Title 5 Official., Inspection FOAM - N Subsurface Sewage Disposal System Form,--,Not for Voluntary,Assessments A 14 Fortes Way Property Address ,, t. .;, Jeffery Beggs Owner Owner's Name r; information is ` required for every Osterville + .� et MA 02655 5-5-21.1 page. City/Town ;y-. State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable.to All Systems: (cont.) , , Yes ,,.,No . f}: fit C ' ' 'i• * 'i • .•3 - .• ri .. "T. 4 '. .' �., ❑ ® Sfatic liquid level in the distribution box above 6'iet 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 -•r i -'than %day floW'y ' ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: '-1 ❑;, . ® ,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 ' ' ''`❑' ® t tributary .to a surface water supply: I ' j Any portion of a cesspool or privy is within a Zone 1 of a public water supply t ❑ r ® t`r ' Well. it+);l f' , r c t~ • ❑ ® t '' ' Any'portion''of a`cesspoofror�pnvy is within 50 feet of a private Water supply well �. ..i . . ❑ ® '• - 'Any portion of a cesspool or privy is less than 160 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This s .r system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence r r , of ammonia nitrogen and nitrate nitrogen is,equal to.or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis . *;. and chain of custody,must be attached to this form.], The system is a cesspool serving a facility with a,design flow of 2000 gpd- ❑ r. ®t ' .I "10;000 gpd t-" .tj. ►. ` r The system fails. I have determinedtl at one or more of the above failure ' ❑ ®` �' criteria exist as descrit?ed in 31'0 CMR)5.303,therefore the system fails. The ,ti„ . , ,t F•. i system ownershould contact the Board of Health to determine what will be .1,necessary,to correct the.failure..f, 5) Large Systems:To be considered a large system the system must serve a facility with a design " flow of 10,00o god to 15000'god." - For large systems., you must indicate either"yes",or"no",to each of the following, in addition to the 1.-..questions in,Section CA. ,,,�,r, .`k. ._._r. , +.. ,�, .;�� .`�.._,,,� . �. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of,18 •. c Commonwealth of Massachusetts Title 5 Official inspection FOriiv , r w"` Subsurface Sewage Disposal System Form Not for Voluntary Assessments ` 14 Fortes Way =r'L7�-•T,iy4- J Property Address Jeffery Beggs Owner Owner's Name information is required for every Osterville MA 02655 5-5-21 page. City/Town + • State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5'the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner `should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No , ' 0 - ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system,components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not ® ❑ available note as N/A) '® - ❑ Was the'facility or dwelling inspected for signs of sewage back up? { ® ❑ Was the site inspected for signs of break out? [E ' ❑ 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? ® Wasthe facility'owner(and occupants if different from owner) provided with El information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health'. ® ❑' 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)] t _ t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts ,,:,_ _. � ,-•>_ -r ,F�'r. ,, !-�: ,, ; Title 5 Official. l nspection Foem ': : r p Subsurface Sewage Disposal System.Form;Not for,Voluntary Assessments o, 14 Fortes Way :r'r�xf.1 Property Address Jeffery Beggs Owner Owner's Name information is required for every Osterville Z; 7r"1 4 J MA 02655 5-5-21,ifk ^i page. Cityfrown State Zip Code Date of Inspection D. System Information =rr -;� � 1. Residential Flow Conditions: �, �; -� `.;'c,. f-;l"k-j b"li, -i, Number of bedrooms (design): 3 Number of bedrooms,(actual): 3 DESIGN flowbased on 310 CMR 15.203 (for,example: 110 gpd x,#of bedrooms): 330 Description: � 1'.q ? 4cc Oil r nt. E Number of current residents: "I,--:, t;l I , , r ,Vc—r i,-11,, t,,, 2 Does residence have a garbage.grinder? ,-.,,, ^f r,f t,;;F,^q t ❑ Yes '® No Does residence have a water treatment unit? ;r, . _ ; ,'r, r,r ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) 1'. ,s a + .` ;i ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail r+ .' .. `':a: .,.�rw•t ;,;# �,F ft-�; t> {.a'; Ii13�,�Pit '.a'�. ` '�. Sump pump? •`- ;i`X-WQ s4"tih • Z-Z �t El Yes ® No Last date of occupancy: 5-2021 't�.,.j^��+�;=3 },Cry• ,,t�� `at.�._..ct(,r��:�.t"� :' -I.. Date � '14fhk1'll t5insp.doc•rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 - Commonwealth of Massachusetts Title 5 Official Inspection Form i� ws Y1I�i Subsurface Sewage Disposal System Form=Not for Voluntary Assessments' � ._ 14 Fortes Way Property Address Jeffery Beggs Owner Owner's Name information is required for every Osteryille t MA 02655 5-5-21 page.. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type'of-Establishment: - Design'flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: { Last date of occupancy/use: " ' Date Other(describe below): r. , 3. Pumping Records: Source of information: Owner----pumped 2017 Was system pumped as part of the inspection? ❑ Yes ® No w If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 ^k, Commonwealth of Massachusetts _,- �� Title 5 Official, Inspection. Foy : 1.1 t o Subsurface Sewage;Disposal System Form,-Not for Voluntary;Assessments .- r� 14 Fortes Way c4 j ; Property Address Jeffery Beggs Owner Owner's Name information is required for every Osterville-� 3 :+ ,„• MA 02655 5-5-21 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) -,� _;;; ,;•i�,�t r:v. ,,., , . � 4. Type of System: i ® Septic tank, distribution box, soil absorption system, 4• ❑ Single cesspool n ' ❑ i;r, �:Overflow cesspool; :rFr ti =• „��_ _. ❑ 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;contracts . ❑r t f,,.,Tight tank:-Attach a copy of,the DEP approval.-I b%r.rjo'c+ ,, ❑ Other(describe): Approximate age of all components;;date installed•(if known) and source of information: 1995 Were sewage odors detected when arriving at the site? .•,t,� r; ,, '� ° s n�;f, ❑' Yes ® No 5. Building Sewer(locate,on site plan): . ,�, ,,;,;_, ,, :r.2 0.•:, ,I;„ ,� ., ; F:,; Depth below grade: --feet F Material Of COnstrddtion:"t;l �.?n t;,l�+: :1' 1. .'.il.i ')� ,f�°£� �,;f , r. .*.1�tf•t" -�jt�,"1 i4`r 7 ,+<,t•17 F;?�.f'' ,1 sTf.e,f d �` �J�I.1 r� a',yS`' '6:�C'�`i�f`�F�:i � + S ® 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.): Good condition. t5insp.doc•rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 ;t Commonwealth of Massachusetts .f Title 5 Official, Inspection Forte � i Subsurface Sewage Disposal System Form =Not for Voluntary-Assessments r Fo rtes ortes Wa t y . ._r Property Address .. Jeffery Beggs z''i if Owner Owner's Name information is MA 02655 ill tesrye' 5-5-21 required for every Ci '" '' • page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): °a '• Depth below grade: r ' 12" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑•polyethylene- ❑ other(explain) j,• " 0 �.t..•, r If tank is metal fist age: i years Is age confirmed by a-Certificate of Compliance? (attach'a copy''of certificate)- ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" ' Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 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 15" . How were dimensions determined? Tape•, Comments (on pumping recommendations, inlet and outlet tee or,baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,•etc.): . Tank is in good condition with baffles installed and,no sign of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f Commonwealth of Massachusetts a Title 5 Official Inspecti®h-FoerTi- A) Subsurface Sewage Disposal System Form,-Not.for,Vol untaryAssessments �1z. yl 14 Fortes Way o ; Property Address , Jeffery Beggs ,• : , �, , Owner Owner's Name information is + required for every OStervllle' p ,; L-f.,t MA 02655 5-5-21'd page. City/Town "_1 State Zip Code Date of Inspection D. System Information (cont.) :^c;, 7. Grease Trap (locate on site plan): („„r, ''. ,,,i; Depth below grade: £° feet'` - t Material of construction: • ,,r, , ,;; ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t :: .. t�,. - ; .:f d -� r,:,t,r,1, Date" Comments (on pumping recommendations, inlet and outlet tee or baffle-condition, structural integrity, liquid levels as related to outlet'1nveit; evidence of leakage;etc): tt _ d k:..r .. a J'.f Fbi N ']..+ w.•. 4'•' W/r ..,. , .'}r+ t. ,r•' I r" 'a t t ua -t,.. .:t�' "?I� tr..., .!.r i A_I... I. :i#�n �.,i1..f,„!'t',4r,�, . - i '.St, 'a U.% I„^d: Wks �i,iv�, ktk! :,�.'•rSif . '4. e,Y.�'°.4{�if4+fl�'. 't ,.jrY 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: - - ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 r$... - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 , Commonwealth of Massachusetts Title 5 Official inspection Forte ill Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Fortes Way Property Address Jeffery Beggs Owner Owner's Name information is required for every Osterville, MA 02655 5-5-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) - Alarm present: ❑ Yes ❑' No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Datef Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): ` Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts a Title 5 Official nspec$i' m �®gym - > I Subsurface Sewage Disposal System Form :Not for Voluntary,Assessments ,.iij-i,.J„ `" 14 Fortes Way + Property Address ,, A ;;. Jeffery Beggs Owner Owner's Name information is Osterville "'f; -"' MA 02655 5-5-21 f required for every page. City/Town R , State Zip Code Date of Inspection D. System Information (cont.) f. 10. Pump Chamber(locate on site plan): I,-,i, ` ,�'F.�r i"l.j+Li�r,f �'»l ,;,1 i1. ri"'��`.:•:[• f i;T,`I:d'1 -irl, - r Pumps in working order: ❑` Yes" ❑ No* Alarms in'worki' order'"r jz,11 : :+;., .w °,n ,tip} ,�':�;,jra,•4'. El i'Yes ❑ No 'i.dt.ilt'r;1 , .. r :�..�l, F. i��.' ,•:.Irt'.; .� ,r� ,f Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): ' � 1 .. . _ ! .a J '�-- l: Li! •.�- r•.J .- .... . ! _.f r .i.1. .wa" .• * If pumps or alarms are not in working order, system is a:conditional pass.^ct",V, 11. Soil Absorption System (SAS) (locate on site plan, excavationinot required):, If SAS not located, explain why: ; u +,,.r•„ I0 III' RAIL.• L +. ai{..r'.m';aw -..( . .!!. Type: "- r,uj t ,I A,i 11001[:.111.1 t �,<, a I,,,-, ® leaching pits . , ;X,'t 0. :pia Jtr� :, r,number: :f?.;.►�N r/�� 1-1000 gal ® leaching chambers- number: 4-Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System!Page 13 of 18' Commonwealth of Massachusetts Title 5 Official Inspection- ,-form,' r , s i�t Subsurface Sewage Disposal System Form -'Not for,Voluntary Assessments •. , ` � sr•T,, .> 14 Fortes Way J Property Address Jeffery Beggs Owner Owner's Name 1 information is Osterville MA 02655 5-5-21' required for every page. City/Town > State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) 4 Comments (note condition of soil, signs of hydraulic failure, level of ponding,.damp soil, condition of vegetation, etc.): Infiltrator fiels in good working order and empty at inspection with no sign of back-up. Leach pit was holding 24" of water with stain line at 36" below inlet invert. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration t-i Depth—top of liquid to inlet invert , Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes. ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 < � Commonwealth of Massachusetts , _, Title 5 Official Inspection Form—, Y, + hl Subsurface Sewage Disposal System Form,,-Not for.Voluntary Assessments. 14 Fortes Way Property Address - Jeffery Beggs �, ,, , r,•,i. Owner Owner's Name information is required for every Osterville MA 02655 5-5-21. page. CitylTown - State Zip Code- Date of Inspection D. System Information (cont.) ,, c• . ,� ,� , y , 13. Privy (locate on site plan): y. `+ -_ ' ' f =: . :1 • ,:, 18,' , 11.1 ... t ' . .� Z , iri`. !f',. ! rr•.�.)�.`�-'i:. =a��.. - .Sf.i,.� ct �'':5rt " ..! ' L Materials of construction: Dimensions Depth of solids Comments (note condition of soil,,-signs of hydraulic failure, level of ponding, condition of vegetation, etc.): a 1�..- ,. .-. -.. _... -- .. . rw4. -�� V - �r� . r •.- ._4. +war w-.d,- -. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts w Title 5 Officisl Inspection Fay'rm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Fortes Way Property Address Jeffery Beggs Owner Owner's Name information is required for every Osterville MA 02655 5-5-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately o 3 U0 A/- JAY 3j I Q t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 f Commonwealth of Massachusetts _ r�-,:f;.- - �, ,► ►,y . , , Title 5 Official Inspectioh Form. . r�l Subsurface Sewage,Dis osal System Form,-Not,for Vol unta Assessments, 14 Fortes Way ,,r •,.,• Property Address Jeffery Beggs Owner Owner's Name ' information is Osteryille ? ;' .., a MA 02655 5-5-21, required for every '-' page. City/Town State Zip Code Date of Inspection , D. System]fiformation (cont )�;',.to 0: a ; , # a'►`�� 15. Site Exam: ❑ Check Sloe .:- ❑ Surface water ❑ Check cellar �tr:e. t ttt •...,., i,:s ❑ Shallow wells Estimated depth to high groundrwate,r... 12'+ t feet; s- i Please indicate all methods used to determine the high ground water.elevation: ® Obtained from system design plans onsecord flf checked; date of-design plan reviewed:,, ,:Date ® ;Observed site (abutting property/observation hole within•150,feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 .a t - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts 0C " a Title 5 O f'idai, inspecti®n.foem Subsurface Sewage Disposal System Form Not for-Voluntary Assessments 14 Fortes Way Property Address Jeffery Beggs Owner Owner's Name information is required for every Osterville " MA 02655 5-5-21 `' r page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist- Complete all applicable sections of this form inclusive of: =` ® A. Inspector Information: Complete all fields in this section. ' } ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate ' 4 (Failure Criteria) and 6 (Checklist) completed;'-'-' ® D. System.Information: t For 8: Tight/Holding Tank—Pumping"contract attached For 14: Sketch of,Sewage Disposal System drawn on pg. 16 or attached -For 15: Explanation of estimated depth to high'groundwater included i e' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 14 Fortes Way. Osterville, MA Name of Owner: Jeff Beggs Address of Owner: Same Date of Inspection: December 15, 1998 t Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15�000) Company Name: James M. Ford Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map: 142 Telephone Number: (508)862-9400 Parcel: 162 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes Conditionally Passes Needs Further Eval on By the Local Approving Authority ails Inspector's Signature: Date: December 28, 1998 The System Inspector shall sub copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS -91 199.g . TOWNOFBgPoy S IrFAL*D&r ti revised 9/2/98 Page lofll Pruned on Recycled Paper r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 14 Fortes Way, Osterville, MA r Owner: Jeff Beggs Date of Inspection: December 15, 1998 INSPECTION SUMMARY: Check A, B, C, or D. A. SYSTEM PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. r 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. Indicate yes,no, or not determined(Y,N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health) broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health); broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A z CERTIFICATION (continued) Property Address: 14 Fortes Way, Osterville, MA Owner: Jeff Beggs Date of Inspection: December 15, 1998. C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health mi order to determine if the system is failing to protect the public health, safety and 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 THE PUBLIC HEALTH AND 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, — 1� 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(W and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a . private water supply well,unless a well water analysis.for coliform bacteria and volatile organic compounds indicates that the Well is free from pollution from that facility and the presence of ananonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER r � I a S . revised 9/2/98 Page 3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FORM PART A CERTIFICATION (continued) Property Address: 14 Fortes Way, Osterville, MA Owner: Jeff Beggs Date of Inspection: December 15, 1998 D. SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: _ I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than'/z day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes" or "No" as to each of the following: „ The following criteria apply to large systems in addition to the criteria above: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 iti a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone II of a public water supply well The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2).. Please consult the local regional office of the Department for further information. _ revised 9/2%98 Page 4 of I I ! I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 14 Fortes Way, Osterville, MA Owner: Jeff Beggs Date of Inspection: December 15, 1998 Check if the following have been done: You must indicate either"Yes" or"No" as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ _ As built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. ✓ _ All system components, excluding the Soil Absorption System,have been located on the site. ✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,.depth of scum. The size and location of the Soil Absorption System on the site has been determined based on:- ✓ _ Existing information. For example,Plan at B.O.H. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] ✓ _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 14 Fortes Way, OsterWile, MA Owner: Jeff Beggs Date of Inspection: December 15, 1998 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): 3 Number of bedrooms(actual): 3 Total DESIGN flow n1a Number of current residents: n1a Garbage grinder(yes or no): No Laundry(separate system)(yes or no): No; If yes, separate inspection required Laundry system inspected(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available(last two year's usage(gpd): 1998-89,000 gals.:1997 91,000 gals: Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL: Type of establishment- Design flow: wA(Based on 15.203) Basis of design flow 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) 4 Water meter readings,if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information; Punwed on October 12 1998 per treatment plant System pumped as part of inspection(yes or no): No If yes, volume pumped: _gallons Reason for pumping: TYPE OF SYSTEM ✓ Septic tank/distribution box/soil absorption system Single cesspool .Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information; Added infiltrators in 1995. Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Fortes Way, Osterville, MA Owner: Jeff Beggs f Date of Inspection: December 15, 1998 BUILDING SEWER: _ (Locate on site plan) Depth below grade: Material of construction: _cast iron 40 PVC _other(explain)' Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting,evidence of leakage,etc.) SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 8" Material of construction: ✓concrete metal _Fiberglass _Polyethylene _other(explain)' If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 8'x S'x 4'6' Sludge depth: 3° Distance from top of sludge to bottom of outlet tee or baffle: 28° Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 11° Distance from bottom of scum to bottom of outlet tee or baffle: 10° How dimensions were determined: Measuring stick Comments: e (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) The baffles were present The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete metal _Fiberglass Polyethylene _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Fortes Way, Osterville, MA Owner: Jeff Beggs Date of Inspection: December 15, 1998 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or at time,of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete metal Fiberglass _Polyethylene other(explain) Dimensions: Capacity: gallons Design flow: gallons/day , Alarm present: Alarm level: Alarm in working order: Yes No— Date of previous pumping: Comments: (condition'of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: ✓ (locate on site plan) , Depth of liquid level above outlet invert: 0° Comments: (note if level and distribution is equal,evidence of solids carryover,evidence ofleakage into or out of box,etc.) The box was level and there were no signs of carryover. - PUMP CHAMBER: None (locate on site plan) r Pumps in working order: (Yes or No) Alarms in working order: (Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) � P revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'.FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Fortes Way, OsteMlle, MA Owner: Jeff Beggs Date of Inspection: December 15, 1998 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits,number: 1 -6'x 6' leaching chambers,number: leaching galleries,number: leaching trenches,number,length: 4 infiltrators (per as built card) leaching fields,number,dimensions: overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) The pit was dry at the time of inspection The infiltrators were not inspected. The bottom of the pit to tirade was 8'6". CESSPOOLS: None (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.) revised 9/2198 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Fortes Way, Osterville, MA Owner: Jeff Beggs Date of Inspection: December 15, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) O O O r g i E3rg . A - . A bjw 3`I ->'a, InQ 33� • * ^'�AI y'� C revised 9/2/98 Page 10 ofll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION -FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Fortes Way, Osterville, MA y Owner: Jeff Beggs Date of Inspection: December 15, 1998 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 52 Feet " Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc:) Determined from local conditions ✓ Checked with local Board of Health Checked FEMA Maps Checked pumping records } Check local excavators, installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Using the Barnstable Water Table and Topographic maps, the maps were showing 52' to groundwater at this site. r This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees; either expressed, written or implied, relating to the system, the inspection and/or.this report. revised 9/2/98 Page 11of11 L COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI DEPARTMENT OF ENVIRONMENTAL PROTE 19 f ONE WINTER STREET, BOSTON MA 02108 (617)292.5500, n k- 29 RUDY E - � e ry 4* ARGEO PAUL CELLUCCI a TRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART A CERTIFICATION Property Address: 14 Fortes Way, Osterville, MA Name of Owner: Jeff Beegs Address of Owner: Same Date of Inspection: December 15, 1998 Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) " Company Name: James M. Ford _ Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map: 142 Telephone Number: (508)862-9400 Parcel: 162 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes ° Conditionally Passes Needs Further Eval 'on By the Local Approving Authority ails Inspector's Signature: Date: December 28, 1998 The System Inspector shall su copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page I of II Printed on Recycled Paper �. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A r—DaPrte CERTIFICATION (continued) topertyiAddr�: 14Frtes Way, Osterville, MA ner: J f ff Beggs of Inspection: December 15, 1998 INSPECTION SUM M A Y: Check A, B, C, or D: 11 ,- / `ti,""1 i A. SYSTEM,PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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. Indicate yes,no,or not determined(Y,N, or ND). Describe basis of determination in all instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health) broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 14 Fortes Way, Osterville, MA Owner: Jeff Beggs - Date of Inspection: December 15, 1998 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and 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 THE PUBLIC HEALTH AND 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. r 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 AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. 1 _ The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER y, redised 9/2/98 Page 3ofII 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 14 Fortes Way, Osterville, MA Owner: Jeff Beggs Date of Inspection: December 15, 1998 D. SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: I have deternrined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this deters ination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 '/a 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 14 Fortes Way, Osterville, MA Owner: Jeff Beggs Beggs Date of Inspection: December 15, 1998 Check if the following have been done: You must indicate either "Yes" or "No"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant, or Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have.not been introduced into the system recently or as part of this inspection. ✓ _ As built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout: ✓ _ All system components,excluding the Soil Absorption System,have been located on the site. . ✓ _ The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for conditions of baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: ✓ _ Existing information. For example,Plan at B.O.H. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)]. ✓ _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSu face Disposal Systems. a revised 9/2/98 Page 5oflt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 14 Fortes Way, Osterville, MA Owner: Jeff Beggs Date of Inspection: December 15, 1998 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): 3 Number of bedrooms(actual): 3 Total DESIGN flow n/a Number of current residents: n/a Garbage grinder(yes or no): No Laundry(separate system)(yes or no): No ; If yes, separate inspection required Laundry system inspected(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available(last two year's usage(gpd): 1998-89,000 gals.; 1997-91,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: tpd(Based on 15.203) Basis of design flow 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Pumped on October 12 1998 per treatment plant System pumped as part of inspection(yes or no): No If yes, volume pumped: _gallons Reason for pumping: TYPE OF SYSTEM ✓ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: Added infiltrators in 1995. Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Fortes Way, Osterville, MA Owner: Jeff Beggs Date of Inspection: December 15, 1998 i BUILDING SEWER: _ (Locate on site plan) Depth below grade: Material of construction: _cast iron _40 PVC _other(explain). Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,etc.) SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 8" Material of construction: ✓concrete metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 8'x 5'x 4'6" Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 11" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How dimensions were determined: Measuring stick Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) The baffles were present. The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal -Fiberglass Polyethylene _other(explain) Dimensions: Scum thickness: `. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Fortes Way, Osterville, MA Owner: Jeff Beggs Date of Inspection: December 15, 1998 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present: Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: ✓ (locate on site plan) Depth of liquid level above outlet invert: 0" Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box, etc.) The box was level and there were no si ns of carryover. PUMP CHAMBER: None (locate on site plan) Pumps in working order: (Yes or No) Alamos in working order: (Yes or No) Corranents: (note condition of pump chamber,condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) r Property Address: 14 Fortes Way, Osterville, MA Owner: Jeff Beggs Date of Inspection: December 15, 1998 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: } Type: leaching pits,number: 1 -6'x 6' leaching chambers,number: leaching galleries,number: leaching trenches,number,length: 4 infiltrators (per as built card) leaching fields,number, dimensions: e _ overflow cesspool,number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding;damp soil, condition of vegetation,etc.) The pit was dry at the time of inspection The infiltrators were not inspected. The bottom of the pit to tirade was 8'6". CESSPOOLS: None (locate on site plan) d 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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: . (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) , revised 9/2/98' Page 9oftt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14 Fortes Way, Osterville, MA Owner: Jeff Beggs Date of Inspection: December 15, 1998 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) O O O A G� .T-0 ST as D-box a9 A - -ram P,+ a°► , A _ T s�c� �-boc 3`I � -i'a In�A) 33� C revised 9/2/98 Page 10of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 14Fortes Way, Osterville, MA Owner: Jeff Beggs Date of Inspection: December 15, 1998 NRCS Report name G Soil Type Typical depth to groundwater f USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 52 Feet Please indicate all the methods used to determine High Groundwater Elevation- ` Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions ✓ Checked with local Board of Health Checked FEMA Maps ` Checked pumping records Check local excavators, installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Using the Barnstable Water Table and Topographic maps, the maps were showing 52' to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection: This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. - revised 9/2/98 Page 11of11 Massachusetts Department of Environmental Management Office of Water Resources 9 TYPE OR PRINT ONLY Well Completion Report gWE A Address at Well Location: -S 1 0 d7,, °"'Property Owner: UPS �` l�/ ( / L' . Subdivision Name: �� Mailing Address: V49 RQ CDC �itCr7` ,:: i4C E. �y3-azl-a�; City/Town: Q%:5r Vi City/Town: A Assessors Map Assessors Lot#: NOTE: Assessors Map and.Lot# mandatory if no, dress available Board of Health.permit obtained: Yes ❑ Not Required& Permit Number ssue 'EVNew Well ❑ Abandon ❑ Domestic ❑ Irrigation ❑ Cable Auger ❑ Deepen ❑ Recondition Monitoring ❑ Municipal ❑ Air Ha A Direct Push ❑ 'Replace ❑ Other ❑ Industrial ❑ Other ❑ Mud3ita - Other cc Unconsolidated Consolidated W Permeability Q _ro From (ft) To (ft) High Low. U `� g m Other Rock Type ! i r f ^`" i r From ft To ft Casing T " d Material -Size O.D. in Well Seal Type Total�epth Drilled O O 9 Yf�� (� )'Da te Drilling Complete _ . - m O r From (ft) To (ft) Slot Size Screen- pe and MaterialScreen.Diameter . r Developed? El Yes ��:No From (ft) To (ft) Material De 4 nption Purpose Fracture ` eALTa,i.! Enhancement? El Yes . X�lo tom! l"f' CW7-6& S rL. Method = r a Disinfected? ❑ Yeso _ Yield Depth Below Plumped Drawdown to Time . Recovery to Date Method (GP : min) (Ft. BGS) (hrs& min) (R.BGS) Date Measured Ground Surface (FT) a_ Pump Description Horsepower Pump Intake.Depth (ft) . Nominal Pump Capacity (gpm) This well was drilled and/or aba ned under ,y supervision, according to.applicable_:rules and regulations, and this repo -,`s complete nd corr t to the best of ny knowledge. Drill ' upervising Driller Signature: / (. istration #: 6 141 Date: 3 Rig Permit#: �''� NOTE: Well Completion Reports must be filYd by the registered well driller within 30 days of well completion. +, :^F e k-� '�� a-.:.'� >I 'o.-.. x t �e,� ' ?. s ->4i � Ii�YGR R*A 3 4'G'A. i'y s. v# �G �• ' � -.``^F S"'3} t. $'t e. ;k:z' -.i - — 2- TOWN OF-BARNSTABLE c� Ac-ATION SEWAGE # /9k) P* VILLAGE ASSESSOR'S MAP & LOTj� INSTALLER'S NAME & PHONE NO. acol- -)-7y-S•`oqq SEPTIC TANK CAP��A��CITY , i�• [2 13(� + LEACHING FACILITY.(type)r C.� �� L F E (size) (.'ir NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER '.. s DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: t"` x VARIANCE GRANTED: Yes NoM . a - ,� ,� �,/ 3-3 LOCATION bl's6-T/ SEWAGE ^PEtMIT NO. T - tiILLACE VISTA LLER'S NAME i ADDRESS -IseC�ly �iUBT - 11MILDE D OR OWNER DATE PERMIT ISSUED DATE C0M.PIIAMCE ISSUED ..,�, �, ..... f �� '� 1 ��, Jo �- �o T ,8 �a` �o�s ��y __ lLa No.... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABL.E Appliratilan for Diipnial l >ark.6 Toutitrnrtinn riovrmft Application is hereby made for a Permit to Construct ( ) or Repair (V) an Individual Sewage Disposal System at: ----------------------------------.............................................................. or Lot No. • /� l5'nCI ddress w ? /�I� . Installer Address Type of Building Size Lot............................Sq. feet ►� Dwelling—No. of Bedrooms------3____________________________----Expansion Attic ( ) Garbage Grinder (NZI) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures . -------------------------------------- W Design Flow____________________________________________gallons per person per day. Total daily flow..__._._.___........__._........__.___.___._gallons. WSeptic Tank—Liquid capacity OQu_gallons Length________________ Width---------------- Diameter_............. Depth................ x Disposal Trench—No_ ____________________ Width--------------------- Total Length-------------------- Total leaching area--------------------sq. ft. 3 Seepage Pit No________ __________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water_._____._._-____---___- rX4 Test Pit No. 2---------------_minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -------------------------------------....................................................................................................................... 0 Description of Soil......................... x x •----•--------- -------------------------•---------.......-----------'------------------••----•... V Nature of Repairs or Alterations—Answer when ap licable._. _ _..___ _..� _� l� A .____�GC;,A/l----- c�[ ...ac�6,AJ ---------�--a-- �'�_.(k-Skn .......---------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli ce has been issued b ard-aftr�alth. / Si ......... ..................... --o----. 1a`.......... .` e re Application.Approved By ----- --- -------- ----------- ------------- Application Disapproved for the following rear on - -------------- ---------------------- ------------------------------------------------------------------------------ ----- ------ ---------------------- -------- ------ ------------ ,� � �-----------------..... _Permit No. - Issued C , �///�� .....Lf//91f,/ Date t ` --- cl THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE —� Appliratilan for Di-npo!ial Wor1w Towitrnrtion 1hrntit Application is hereby made for a Permit to Construct ( ) or Repair (V) an Individual Sewage Disposal System at: YC Location-i�ddress { or Lot No. L/ ............................... ener dress ae ..�`'` ---------------------------------------- ._.. Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms------3--------------------------- ----Expansion Attic ( ) Garbage Grinder N&) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( )' P4 Other fixtures ------------------------------------------------------ W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liqu (Ybid capacity_ I.galIons Length---------------- Width--------.------- Diameter---------------- Depth------------- x Disposal Trench— No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...................... Diameter-------------....... Depth below inlet.................... Total leaching area..................sq.--ft.-,.-_ z Other Distribution box ( ) Dosing tank ( ) " Percolation Test Results Performed by................ ......................................................... Date....----................................. a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ g�, --------•---......---•-•-------•---•-------•----••••---•••-•-••--•••--•--•-------••-•-•••••••--•-------•--•-•---•---•-•---•---•..............•--••----.•--•- Descriptionof Soil...................................................................................................................................................................., x ......................-------------------------------------------------------- -----------------•--- ------ --- -{------ ----- i- U Nature of Repairs or `' erations—Answer when ap licable.... V_--.-.i_..� 9_� .,.....0 C . .W..Atn-------4k ----------- -------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of ComplkLqce has been issued b_tb2 eard-af-health. Si .................. ----- . ... ....._............... ... ..r---------........---------� y, JO re Application.Approved By ...... ................... ` - -oa4e Application Disapproved for the following reafons- ------------ ----------------...-.--....--......_------------------------------ -....... ........ ....... . - _.._............................... - _.... .... ..........----...............................................-.....--------- f. - ----------------................ ... Dare ---- - ` Permit No. ... . ...... - - Issued ------------- ------- . Date I � 9 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE GPLtifi ate of (11—ampliance TH S IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�) by ..._..-. .WY ."`...-�r.r�-- 1. .._-...-.-_..._... - .............__... ... ..__ --------------------------------------------- at .. k Q.S...... W -------.e---------------------------------------------------------------------------..------------------ has been installed in accordance with the rovisions of TITLE of The St riv iron mental Code as described in the application for Disposal Works Construction Permit No. -..:.- ....-_.--- dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CON TRUE AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.. . Ins ectr .DATE � �. ....... .. THE COMMONWEALTH OF MASSACHUSETTS �. BOARD OF HEALTH 95loo� TOWN OF BARNSTABLE No. FEE.---•-••--•.:........... a�. '`Dispoii l Workii Tomitrudion "Urrntit Permission is hereby granted----- a- c- ------------------------------------------------------------------•--...--•----•--••---•--. to Construct ( ) or Repair ( \.�an Individual Sewage D•s osal System No. �?rk25 - 1-� ----------------------------------------------------- at Street ated. ✓? . as shown on the appli tion for Disposal Works Constructton e It No. _ ______________ _. ._. _ of d DATE..............Q.�.. Y, -------------------------•---- Boar ealth FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS L—T Na ....l. s/ y Fxs...7...0............... COMMONWEALTH OF MASSACHUSETTS BO,,eR® OF HEALTH ....... OF.... ( . .........--..41.... ................ Application f ur � _Wiallftrks Tonstru.rtinn ramit Application is hereby made for`a Permit to Construct ( " ) or Repair ( ) an Individual Sewage Disposal system a 1 . - .. Location-Ad ess . ` o Lot No. //. O ner Add ss Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.__ Expansion Attic ( ). Garbage Grinder ( ) a � Other—Type of Building 4LaiRe_r.,.-1..__..._.. No. of persons.........�.�............... Showers (� — Cafeteria ( . ) Otherfixtures -----•------------------• -_--_-_----_-------------------------------------------------------•--------•----------•----.--..------------------ 1. W Design Flow............................................gallons per person peyday. Total daily flow-----:,� .O...................gallons. WSeptic Tank—Liquid capacit/j011Ogallons Length...... ....... Width.......... Diameter---------------- Depth................ x Disposal Trench—No. .................... Width. ................. Total Length____-_--_.......... Total leaching area............ , sq. ft. Seepage Pit No--------- Diameter._____ ______ Depth below inlet......_........ Total leaching areaa;.? .:. sq. ft. Z Other Distribution box ( ) Dosing tank�_ )` r a Percolation Test Re;?Its Performed by.......... ../ � `� ::.........Date_._,�C�_ ...:Z_L�.- .._.II. erj ,.a Test Pit No. 1 LL�..minutes per inch Depth of Test Pit________•••____-___- epth to ground wa er________________•_-.--_. fTq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a /-+ O Description of Soil----- fit ' [�s' --------•----------•---------- ----------------------------- x W ------------------------- ---------------------------------------------------- -------------------------------------------------------------------------------- •------------------------------------- •-•- UNature.of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI'L11 5 of the State Sanitary Code— he undersigned further agrees not to place the system in operation until a Certificate of Compliance h been is ` by the board health. gned--_ ......../ -------- �.� Application Approved B .._. - �Y Date Application Disapp ve or he following reasons:................................................................................................................ ................................... ......•--------•-•-•••------------------------._....--------•----'----------------•---••------------------..............................-----Date......------. PermitNo._._ Issued....................................................... Date NS.S.....t rJ-�... Fins...`1.................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH l .� ----------{��..................0F........ ! .,..........----1... Applirtttilan for Disposal 10orkii Tonuarnrtiun ramit Application is hereby made for a Permit to Construct ( } or Repair ( ) an Individual Sewage Disposal System al: A f. . .f __ .O g Location-Ad&,ess i p q Lot No. L, ... . (�S Owner Add ss Installer Address UType of Building ,, - Size Lot....;........................Sq. feet Dwelling—No. of Bedrooms...i ---- �............................Expansion Attic ( ) Garbage Grinder ( ) — Cafeteria p., Other—Type of Building��,�tia_r�_..._.___. No. of persons___._..________________ Showers (� ( ) PL4 Other fixtures -----•......-----•-•-----••••-•• - WDesign Flow............................................gallons per person per, ay. Total daily flow------; ...................gallons. WSeptic Tank.' Liquid capac>t/0 rn--0gallons Length....... ....... Width.... ....... Diameter................ Depth................ x Disposal Trench—No..................... Width.,,................. Total Length....... _:;.:,,,Total leaching area,_.....-..__ _//�sq. ft. Seepage Pit No.....__.�..... Diameter.......0 _.-.-- Depth below inlet.............. Total leaching areas". sq. ft. Z Other Distribution box ( , ) Dosing tank )/ /� Percolation Test Res t� Performed by..___.____ .✓, _' "��'re ._........ Date_._ kr/ _•_- 0�sTest Pit No. lf _.minutes per inch Depth of Test Pit...................• epth to ground wa __________.__.__.. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --------- ODescription of Soil -- ...---- --------------=-•---------•-------------------------••--••--.------ --•-•---.......-----------•- x •-•--•-------------------------------------•----•---------------------------------------------...........................................................=............................................. U Nature of Repairs or Alterations—Answer when applicable----------T-------------:................................:. ........................ --------------•-------------•---......_..------------------•---....-----------••-----------•------------•---------------------------------------,--....-•------------•-------------------................ Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— he undersigned fugher agrees not-to place the system in operation until a Certificate of Compliance ha been iss by the board p ealth. �I Signed- a " ` _..._ proved BYApplication Ap -----------•------------•-------------------- jl.�/ Date Application Disapprove or �he following reasons:------•------------------------------------------------------------------------.....__ . .............. — j -----------•--•-•...-••------•-•------••..........-•-•-•.................. ..••---------- 7 - Date PermitNo......................................................... Issued....................................................... Date . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i ..........................................OF........................... ......................................................... i �rr�gf trtt�e�oaf f�unt�littnrr THIS ,W I , That e Ind idual S wag Disposal System constructed ( �r Repaired ( ) by ...................ff ------- l.. .-- _ :...... ._...at_• ` — , -__-•------Installer--••-•-•--------------•-----------••-•---- has been installed m a rdance with the provisions of TI" r 5 f,,The State Sanitary Code s dqscribed in the application for Disp 1 Works Construction Permit No.- ............ .................. dated-- " .._' ................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............................. -----------------•---•..•..--'. �......... Inspector.................................................................................... A , THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH *' ......................................... L� No.. ..................... FEE..... Permission is reby granted------ . -•-•••.....f__' � _- to Construct-(/ r,,Repair,, an In ivi.ual Sewage isposal System at No... ._.......•--•- le1 Street � as shown on the application for Disposal Wo s Construction Permit.No. ated../ /� --,� �. , Board'of Health DATE............................................................................. -- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - �Y r M1! 1 4 rl OF PAWJ p e,r. 1 ; ;rGI (vAcAiJT TA IV A< MIA w Lj r' `Ja / ,� ,� / c do, �/ �• t vi O I \ r 3 / sG\� qp'u sl X x: Q � Z=,JE Io' S LEGEND CERTIFIED PLOT PLAN EXISTING SPOT ELEVATION . EXISTING CONTOUR --- O -- • /� . AL yV L.� 7- FINISHED SPOT ELEVATION o �; Q� ? 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