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Home My WebLink About0031 GINGER LANE - Health 31 GINGER LANE, OSTERVILLE A=165-010 C I i I . , Commonwealth of Massachusetts of 0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Ginger Lane Osterville Property Address Michael & Niki D'Esopo Owner Owners Name information is required for every Osterville MA 02655 1/9/2021 page. City/Town State ZipCode Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information 1 filling out forms p on the computer, use only the tab James Ford key to move your Name of Inspector cursor-do not use the return Ford Septic Services, LLC key. Company Name P.O. Box 49 ICCCC� Company Address Osterville MA 02655 CitylTown State Zip Code 508-862-9400 S 12482 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 1/19/2021 Inspec 's Signature Date The s em inspector shall submit a copy of this inspection report to the Approving Authority (Board of Hea or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. l5insp.doc-rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts. Title 5 Official Inspection Form V` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Ginger Lane Osterville Property Address Michael & Niki D'Esopo Owner information is Owner's Name required for every Osterville MA 02655 1/9/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 31 Ginger Lane Osterville Property Address Michael& Niki D'Esopo Owner Owner's Name information is required for every Osterville MA 02655 1/9/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Ginger Lane Osterville Property Address Michael & Niki D'_Esopo Owner Owners Name information is Osterville required for every MA 02655 1/9/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS.and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: f Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 31 Gin er Lane Osterville Property Address Michael & Niki D'Esopo Owner Owners Name information is required for every Osterville MA 02655 1/9/2021 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd,to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.1/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <lo Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Ginger Lane Osterville Property Address Michael & Niki D'Esopo Owner information is Owner s Name required for every Osterville MA 02655 1/9/2021 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 ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official ns pection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Ginger Lane Osterville Property Address Michael& Niki D'Esopo Owner Owners Name information is required for every Osterville MA 02655 1/9/2021 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes. ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: uknown Date t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Ginger Lane Osterville Property Address Michael & Niki D'Esopo Owner Owner's Name information isequired or every Osteryllle MA 02655 1/9/2021 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use- Date Other(describe below): 3. Pumping Records: Source of information: pumped in 2018 per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: I gallons .How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Ginger Lane Osterville \� Property Address Michael & Niki D'Esopo Owner Owners Name information is OSterville required for every MA 02655 1/9/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: installed on 6/29/2009 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 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.): I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface s rfac Sewag e ge Disposal System Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form tl; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Ginger Lane Osterville Property Address Michael & Niki D'Esopo Owner Owners Name information is OSterville required for every MA 02655 1/9/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 22" feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal. Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle 23 Scum thickness 1 Distance from top Of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tees were present. There was no sign of leakage. Pumping was done in 2018 and not needed at this time. The outlet filter was clogged and I cleaned it It should be cleaned eve 6 months t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Ginger Lane Osterville Property Address Michael & Niki D'Esopo Owner Owners Name information is required for every Osteryille MA 02655 1/9/2021 page. Cltytrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 El other(explain): N/a Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Ginger Lane Osterville Property Address Michael & Niki D'Esopo Owner Owners Name information is required for every Osterville MA 02655 1/9/2021 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: Date Comments (condition of alarm and float switches, etc.): N/a *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 Even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The D-box was normal. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 l Commonwealth of Massachusetts Title 5 official Inspection Form < Subsurface Sewage Disposal System Forts _Not for Voluntary Assessments v 31_Ginger Lane bsterville Property Address Miwhael & Niki D'Esopo Owner owner's Name information is requirad for every 0 terville MA 02655 C1ty/Town 1 ate of In page. - State Zip Code Date of Inspeption D, System Information (cont.) 10: Pump Chamber(locate or, site plan): Pumps in wgrking order: ❑ Yes ❑ No* Alarms in wgrking order: ❑ Yes ❑ No* Comments (note condition of pump charhber, conditior of pumps and appurtenanCes, etc.): n/a * If pumps Or alarms are not in working order, system is a conditional pass. 11; Soil Absorption System (SAS) (locate On site plan, excavation not required): If SAS not located, explain why: Type. ❑ . leaching pits number: ® leaching chambers number: 12 - bio defttsers ❑ leaching galleries number: ❑ leaching trenches number, Irangth: ❑ 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 (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Ginger Lane Osterville Property Address Michael & Niki D'Esopo Owner Owners Name information is required for every Osterville MA 02655 1/9/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There was no sign of failure from the SAS A camera was used 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ .No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pa P Y ge14of18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Ginger Lane Osterville Property Address Michael & Niki D'Esopo Owner Owners Name information is OSteNllle required for every MA 02655 1/9/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/a Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 4 t5insp.doc-rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts ' Title 5 Official Inspection Form X Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 31 Ginger Lane Osterville Property Address Michael & Niki D'Esopo Owner Owner"s Name information is required for every Osterville MA 02655 1/9/2021 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 3 a s /03 y/ 3 c; a3 y Sbi �s S' 60 3o t51nsp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 31 Ginger Lane Osterville Property Address Michael & Niki D'Esopo Owner Owners Name information is required for every Osterville MA 02655 1/9/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 35' +/- ` 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: Topo and water contours maps ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;V 31 Ginger Lane Osterville Property Address Michael & Niki D'Esopo Owner Owners Name information is required for every Osterville MA 02655• 1/9/2021 page. Cltylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For.8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage,Disposal System•Page 18 of 18 TOWN OF BARNSTABLE '✓ LOCATION l3 ' I SEWAGE # VILLAGE �/i ` Q ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �✓G1,2Q,4 � SEPTIC TANK CAPACITY /CP G9+ LEACHING FACILITY: (type) (size) / Z NO. OF BEDROOMS r BUILDER OR OWNER t' D i PERMITDATE: �COMPLIANCE DATE: a q 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 � � � 1 _ � .�.. t32 � � 3 � � � �-- a r � �, �� .�� '� 3 �t ��,� L� No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0[pplitation for �W!5po$ar *pgtem Cow5trUction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. 31 6 oice L'I Owner's Name,,Address,and Tel.No. w, Assessor's Map/Parcel 14 `� ` &I" f Installer's Name,Address,and Tel.No. Des�Pu's Name,Address and Tel.No. �a73-a-177 Type of Building: Dwelling No. of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building Howe No.of Persons Showers( ) Cafeteria( ) Other Fixtures n Design Flow(min.required) V/J gpd Design flow provided D gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank /,00 0 Type of S.A.S. / `Z / c. ( �!e, ,jjio — Description of Soil Nature of Repairs or Alterations(Answer when applicable) /✓�� le j e 41r1 `6 / Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Anvironmental de and not to place the system in operation until a Certificate of Compliance has been issued by this Board of all Signed Date ��'�Ij Application Approved by p Date ��f 1� Application Disapproved by: Date for the following reasons Permit No. Z�C� 1 _ Date Issued �(,a " � Cal' �....d•• + .. `'4F1 y - . umd No. w �+ .;.� Fee ACl, THE COMM _,NWEA ': Entered in compu er: O _LTH OF MASSACHUSETTS , . PUBLIC HEALTH DIVISION - W TON OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for Mioogal *vmem Cow6truction Permit Application for a Per mit'to Construct( ) Repair( Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. 6,47ce Z j Owner's Name,Address,andT�el.No. Assessor's Map/Parcel /6 %D } � t . a/eA } 1T L�aR • -7FP� Ifll ---------------- ear) � Installer's Name,Address,and Tel.No. Desi�'s Name,Address and TeL No. C " r C Er�y��e•Gi'� �a73~aj77 Type of Building: Dwelling No. of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building f-/0We No.of Persons Showers( ) Cafeteria( ) Other Fixtures Desig Ow(min.required) .� gpd Design flow provided -3 3 O gpd Plan Date Number of sheets Revision Daie Title s 3 Size of Septic Tank ��(] Type of S.A.S. s C R - Description of Soil O/{-PS P Z-S Af- L A N / Nature of Repairs or Alterations(Answer when applicable) lylew le,9 114inti eLl_ fGAf-J s Date last inspected: Agreement: y. " The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the vironmental de and aot to place the system in operation until a Certificate of Compliance has been.issued by this BoaVoflt k Signed Date Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued If!p THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance j THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( �laded ( ) Abandoned( )by oe loe, leh at 31 1l71W„ 'hV has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Z-004- 1-4-5 -dated Installer Designer -�:! C #bedrooms Approved de( i�gn fl6w gpd The issuance of this pe it s all not be construed as a guarantee that the system via+1 n 1ti4 n as designer Date lfl �lu t Inspector No. G-IJC '' ( j. Fee � rr� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1=i!5po,5al *y5tem Co"Ituctton Permit Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon ( ) System located at 31 &r'q.6e_ Z�, and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Constru tion must e completed within three years of the date-of this pe Date /O 63 q Approved by a �::K'VH1T :...,.NWWIw�^�wiil':`�.„:eva+w�x�{•:;�. ,,�mm _ •.. ,.:. .,., .. ,�„ ,_ , Town of Harnsta'ble. AY . 1wp�eda�it etwot7 6rniew f Pabll+G I�fvmon " � ed a � SOU Suitabitily Assessmen t for Sor ew )OC2 tGeti2xc�+Iall TI • u`�u°""aa""3i C'��nC��e Cl, �C (��ens5j t��C�e,✓��.3�8a�1c��S'1vniC A sNspmt Il05 1010 • HOW RIPADt -- � - �- "_ 'r �� 6ue��e itnor. • -= - _ ��'...� .. LIA U. ,fit t�►rtiw�s�uis.�-.-1t �ai�'1VaNiwpl�:�......t ' $�!cMhetet+m.al�a.�e�,t o/�s w.et ya.de�.e[bMlt tor.L pas 1�4�d•«q�wua�rm�r+pr olltdatl $ee- Plat- clat-tcA 2'z 21005 i OLk WaAA r� frtnrt ieWkd t(Mektyet t L 6" ' 7 t 2 b VOOPM 60M ble11110! psobbGtasMNrMs 6{At�yWatrlrWs{s► co . 4si�Ifworol Rila > t z� � � •� D TOWMATION TOR I�R BWAL HIGH WJ1'1'si�'PA�' t Owsuuahv� ` Lidw Wd o�ec t?to 01p11 t0001111It�fW.. G3 00 OWWIM lumoly it ,..... �, Gwaw ►�► `Nrlir ai co rn -1M�piyll� dc6Ll�oie 'Id1gVN..r..:.�.... WPM pucoLkBGN Taff wprrdl!eA 3y _ _ gtr tls Iffy A.>•mmt L1t lh...d . v IlItA3llll.d;..._.r... Aa/ltrtssl7Wr�Wrlid(YJM.�,.� • Ori j1tW!Mblb lEiraNM atv�os Ob10f 1ntTlDn IIo1n bLb�0$0 C�►�Irphibd O{f BiCk t'...-.�..- • «tng j�iv�ols tle�bits Lr to 6e eontlutCted wl"140'd Wdiod,pu a►wk prat llo*ftq 8scsasbLU tbnDtvllion atUsd on (1)Weak PI'to bog*WXW �M - x 14 tT r .. IYJ.G'CICIG ...�L.•.11.'n•..'...:. '..Y••r..•:�.,•'i'c r'•-v- 'i: .:':.1..... ,....:r• • 0 LLL COIOr ••••^�• I�pt�om �silliadpA tbit i�il t�r�eJ `MsDW ,nA■i{Itq :�Ms , to ^ KV 3Y 1-5 %U Yo Sib 3Y'126 G M S 2.5 �. . B�R'�'lT,�ON� •,golaa 2. OEM Viwn Wil lbrtaae �11'{MYaw faU`tft felt M�lt+stbJ NSDW . 06ma Mofts too" 1 10 0Yr516 380 y^l2(v ft Mor lt+�W►) ,'tl�sss� WdUsr Atss�, �sulAas nR'�P bBSE�YATZO ' ' '� N H�LQt�sd too waa aa. sou u� Id Tau" d�a . tooGftr (URA) an.wa Was pnn�t.�t+tesuaseut�e, � I ' AbewtO�isp�sedNeti�t�q Wo..r... Yes� •. . ' �Yltds S00 `/ tro WY tmyisrlleodiieslb ►Me. U/' Dol`atieW is awsuy otu mite w awt Ift tot gnuobwv,W Owsbattfts x[ttp VOW a*Am on abtOrpt O N not, is 1bs dApib e�!A'�usalty eiacin*Pe^'lo1M auterW?.�.,.�.....�� bR+,$ ft tot w0un r�� Da�traesnc at 8 ll tat n tad dut ft above ambsk T) prrAarsut!by w eoeeiwat wOD do r+""Oldnlay ae du l w In$10t 1JA17, • ...._ our a� a9 . . q�ne�e�olw.aoc ,per : \ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �� ` Property Address: 31 Ginger Lane - 0 MA ��A 0 , 2001 Owner's Name: William Naas Owner's Address: TOWN OF SARtvs HEALTH DEP77A8LE Date of Inspection: ,,L ® 7 Name of Inspector: (please print) William E_ • Rob inson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: ( 5 0 8) 7 7 5—8 7 7 6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: I/Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority 'Fails Inspector's Signature: Date: -I-9 —0 / The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approxing authority.. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued), Property Address: 31 Ginger Lane Osterville Owner.• Naas Date of Inspection: . Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. S stem Conditionally Passes: ne or more system components as described in the"Conditional Pass"section need to be replaced or repaire .The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer es,no or not determined(Y,N,ND)in the for the following statements.If"not determined".please explain. e 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 ank is replaced with a complying septic tank as approved by the Board of Health. •A me septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indica ' g that the tank is less than 20 years old is available. ND ex lain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or ob cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with app val of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND a plain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass spection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Pdge 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 31 Ginger Lane Ostervi le Owner: Naas Date of Inspection: 7q - 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 fai ing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the sy tem 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: k 3 Page 4 of I 1 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 31 Ginger Lane Osterville Owner: Naas Date of Inspection: �Z-- ci—D I D. System Failure Criteria applicable to all systems:. You ust indicate"yes"or."no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (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. arge Systems: To a considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no j he system is within 400 feet of a surface drinking water supply he system is within 200 feet of a tributary to a surface drinking water supply he system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well answered"yes"to any question in Section E the system is considered a significant threat,or answered ction D above the large system leas fafled.The awns or operator of any large system considered a threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR e system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 31 Ginqpr Tuna Osterville Owner: Naas ° Date of Inspection: -�L— 5—G t 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' _ZWere any of the system components pumped out in the previous two weeks? - Has the system received normal flows in the previous two week period? zHave 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) t/ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out Were all system components,excluding the SAS,located on site Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the-baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _✓_ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. V _ 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)] 4 - S 5 Page 6 of l 1 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 31 Ginger Lane Os erville Owner: Naas Date of Inspection: ;�. -®5-0 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):16 O Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): G Number of current residents:" 7-. Does residence have a garbage grinder(yes or no):J, Is laundry on a separate sewage system(yes or no):&o [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use: (yes or no):A,e) Water meter readings,if available(last 2 years usage(gpd)): 2000 72,000 gal. Sump pump(yes or no): /i O 1999 97,000 gal. Last date of occupancy: -7 6 -o 2MERCIAL/INDUSTRIAL yp of establishment: Desi flow(based on 310 CMR 15.203): gpd Basis f design flow(seats/persons/sqft,etc.): Greas trap present(yes or no):_ Indus ial waste holding tank present(yes or no): Non-s itary waste discharged to the Title 5 system(yes or no): Wate meter readings,if available: Last ate of occupancy/use: OT ER(describe): GENERAL INFORMATION Pumping Records Source of information: TL i"-w s ` �• Was system pumped as part of the inspection(yes or no): A-o If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: T OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): U 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 Ginger Lane. Osterville Owner: Naas Date of Inspection: B LDING SEWER(locate on site plan) Dep below grade: Mate ials of construction:—cast iron _40 PVC_other(explain): Dis ce from private water supply well or suction line: Co ents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓(locate on site plan} Depth below grade: Material of construction: Xoncrete metal—fiberglass_polyethylene —other(explain) ' If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: Sludge depth: — v Distance from top of sludge to bottom of outlet tee or baffle: 11 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: How were dimensions determined: 6 �" S+ A- )L- Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): _ L ,,Y Jam- bj�c L, GRE SE TRAP:—(locate on site plan) Depth elow grade:— Materi 1 of construction:—concrete metal fiberglass_polyethylene—other ; expla Dime sions: Scu thickness: Distince from top of scum to top of outlet tee or baffle: Dis ce from bottom of scum to bottom of outlet tee or baffle: Date f last pumping: Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as re ted to outlet invert,evidence of leakage,etc.): 7 Page 8 of l 1 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 Ginger Lane Os will _ Owner: Naafi Date of Inspection: GHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Dept below grade: Mate 'a]of construction: concrete metal fiberglass_polyethylene other(explain): Dime sions: Capa ty: gallons Desi Flow: gallons/day Al present(yes or no): Al level: Alarm in working order(yes or no): Dat of last pumping: Co ents(condition of alarm and float switches,etc.): DISTRIBUTION BOX: �' (if P resent must be o ened)(locate on site plan) P Depth of liquid level above outlet invert: 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.): PU P CHAMBER: (locate on site plan) Pu ps in working order(yes or no): Al s in working order(yes or no): Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) . Property Address: 31 Ginger Lane Osterville Owner: Naas Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ ✓eaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number an configuration: Depth—top of liquid to inlet invert: Depth of sol ds layer: Depth of scu layer: Dimensions o cesspool: Materials of c k nstruction: Indication of oundwater inflow(yes or no): Comments(no a condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): t PRIVY: (locate on site plan) Materials o construction: Dimension : Depth of so 'ds: Comments( ote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Ito Page 10 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 Ginger Lang Osterville Owner: Naas Date of Inspection: /-96—n / 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. y 11 LI Y A s 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 31 Ginger Lane Osterville Owner: Naas Date of Inspection: G d—3 G-a SITE EXAM Slope Surface water Check cellar Shallow wells . 1 , Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: �k�served site(abutting property/observation hole within 150 feet of SAS) hecked 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: o �i T a 6 -�� r 4 r . 11 TOWN OF BARNSTABLE Poll LOCATION 4//V A � 1 C SEWAGE # 2- VILLAGE ®�'/��/P 1/f.L F ASSESSOR'S MAP &LOT/4 , G 4 INSTALLER'S NAME&PHONE NO. 01311Y, o X/— 77S 7 7/ SEPTIC TANK CAPACITY /! S LEACHING FACILITY: (type) � 2 &4.4 4 C (size)' NO.OF BEDROOMS B 'OR OWNER A14 /�5 PERMITDATE: COMPLIANCE DATE: 9�7z:�z Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by J � G,4Z.c /r Fee 4 0 . 0 0 NoM. . '.•.s THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pp[icatiou for Migoot *patent Con! truction Permit Application is hereby made for a Permit to Construct( )or Repair( x )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 31 Ginger Lane Mr Naas Osterville MA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. y W.E. Robinson Septic Sery P.O. Box 1089 Type of Building: Dwelling No.of Bedrooms 2 Garbage Grinder( nq Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil sand Nat re off Repa s r alterations(Answer when applicable) install a 1 , 500 g a l septic an k ang 3 #330 high capcity stonepacked infiltrators . Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance f the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Envir nmental Code d not to place the system in operation until a Certifi- cate of Compliance has been issued by this of ealth. Signe Date Application Approved by o Application Disapproved for the following reaso Permit No. Date Issued rI• `F r" .-+..-b. n. � .. ��...... ..1 -,'[-x+,.w-... avWhg..".+e«wa+I:+a+-+„�x. �v �, :J r a,..-.. '�5... ,..- .. .,. .. .. . �"� 4 - ( / 40.00 w Fee ee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS •--- Tipplication for Migool *pgtem Construction Permit Application is hereby made for a Permit to Construct( )or Repair( x)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 31 Ginger Lane Mr Naas Osterville MA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. W.E. Robinson Septic Sery P.O. Box 1089 Centerville 775-8776 Type of Building: Dwelling No.of Bedrooms 2 Garbage Grinder( nq Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil sand Nat re Re a' s �o s( saver whe licabble) install a 1 ,500 gal septic an° a�n'c'� ` iiggli capc s nepacked intiltrators. A Date last inspected: Agreement: x The undersigned agrees to ensure the construction and maintenance f the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the'Envir nmental Code d not to place the system in operation until a Certifi- cate'of Compliance has been issued y this of ealth. Signe i Date ^�o_` n Application Approved by Application Disapproved for the following reaso Permit No. Date Issued q_,o _9 Naas THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS C.ertifivate of Compliance - -' X THIS IS TO�cF�,,RRTIFY that the On-siteSew ye D• )sal System installed( )or repaired/replaced( )on by vT Robinson' Sept�c pery for Mr Naas as 31 Ginger Lane Osterville Z hasybbgen constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ifted Use of this system is conditioned on compliance with the provisions set forth below: y " No. �� Fee 40.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Xi.5pool *pgtent Con!gtructio'h Permit Permission is hereby granted to W.E. Robinson Septic Sery to construct( )repair( X)an On-site Sewage System located at 31 Ginger Lane Osterville and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction m s be co fete within two years of the date below./ Date: Approved by / . o Naas CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) �6 G > hereby certify that the application for disposal works construction permit signed by me dated ' concerning the property located at 6 (� ~� meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED: P o - DATE: . LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. T •� 4 ' l i J ` I PROVIDE PRECAST CONCRETE T.O.F. EL.= 47.2' +- EXTENSION RISER WITH CONCRETE INISH GRADE OVER D-Box= 46.6'+- 4"SCHEDULE 40 PVC MIN. SLOPE 1 % FINISHED GRADE OVER DIFFUSERS = 46.7' - 46.51 GENERAL NOTES COVER TO WITHIN 6"OF F.G. OVER SLOPE @ 2% MIN. INLET AND OUTLET COVERS. REMOVABLE WATER-TIGHT COVER OVER INSPECTION PORT WITH ACCESS BOX TO 1. UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISH GRADE RISER TO WITHIN 6"OF FINISHED GRADE WITHIN 3-OF F.G. (ONE PER TRENCH) METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE ENVIRONMENTAL @ FND. EL.= 46.6'+- FINISHED GRADE OVER TANK EL. = 46.7'+ f-5-DIA. OUTLET(S) CODE AND ANY APPLICABLE LOCAL RULES. 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE DESIGN ENGINEER. PROPOSED 9"MIN. EXISTING 4" PVC SEWER PIPE 36"MAX. 9"MIN. 3. 4" SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL SEWER PIPE 36"MAX. TOP OF SAS B.O. = 43.73' SYSTEM UNLESS OTHERWISE NOTED. 6" 3" 3" DROP MAX PROVIDE WATERTIGHT 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN F 2-DROP MIN 3" 9- MIN.SLOPE 0 1% 1 JOINTS(TYP.) ELEVATION =43.73' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A 10 n7Y;TYP 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF 4"PVC IN FROM 4"PVC OUT TO '-)F F TV 10" 1 14" SEPTIC TANKO F71117:71 EAH .33' 16 TYP THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. LEACHING FACILITY F4zA (TYP.) 0.90, 10.75' TYP 5. SLOPE ALL SOLID PIPE AT 1.0%MINIMUM. 12" 6 CONTRACTOR S 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. CONTRACTOR HALL Al I \-OUTLET TEE 43.60 MIN. lt%J.43' SHALL VERIFY SIZE 48' VERIFY CONDITION OF 43.30' 42.40 (LAID FLAT) -2.875'(34.5') 5.75' 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK AND CONDITION OF EXISTING TEES 22"ZABEL FILTER 6"CRUSHED STONE 5.0'- (TYP.) FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS EXISTING SEPTIC AND REPLACE AS MODEL#Al 801-4x22 OVER MECHANICALLY (TYP.) 11.50' NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH TANK NECESSARY COMPACTED BASE 5'MIN. AND DESIGN ENGINEER. 5 OUTLET DISTRIBUTION BOX 30.0-(TYP FOR BOTH TRENCHES) 8. ELEVATIONS BASED ON APPROXIMATE M.S.L. DATUM OF 48.00' ESTABLISHED TO BE INSTALLED ON A LEVEL STABLE ON A NAIL SET IN A TREE AS SHOWN ON PLAN. BASE. FIRST TWO FEET OF OUTLET GROUND WATER ELEV.= < 36.50' 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION EXISTING 1 ,000 GALLON CONCRETE SEPTIC TANK PIPES TO BE LAID LEVEL. THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT CROSS SECTION VIEW BIODIFFUSER (PROFILE) BIODIFFUSER (END VIEW) 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES 'CONTRACTOR TO VERIFY EXISTING ELEVATION PRIOR SEPTIC TANK PROFILE DISTRIBUTION BOX DETAIL 12 36HC ARC (#3616BD) BIODIFFUS TO THE DESIGN ENGINEER. ERS TO ANY WORK& NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE NOT TO SCALE NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC.STRUCTURES SHALL BE MADE WATERTIGHT. 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING NOTE: NOTE: ENTIRE PROPERTY IS LOCATED WITHIN THE ESTUARINE WATERSHED. 00or • TEST PIT DATA REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM PERC NO. 12513 APPROPRIATE AUTHORITY. 1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF INSPECTOR: Donna Z. Miorandi, R.S. 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE EACH SEPTIC SYSTEM COMPONENT. EVALUATOR: Bradley Bertolo, E.I.T. THEY SHALL WITHSTAND H-20 LOADING. July 2003 C.S.E. APPROVAL DATE: 2.) CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF THE 12 DATE- March 30,2009 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. Ito PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH TEST PIT It TEST PIT#: 1 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE DATA SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL BOARD OF 61 0, 4;, 4 0 Wo * a ELEV TOP 47.00' MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. HEALTH IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. GINGER LANE REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, (40-WIDE LAYOUT) 11 ELEV WATER 36.50' FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). PERC RATE <2 min./inch15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. DEPTH OF PERC= 34"-52" 16. PROPOSED PROJECT IS LOCATED WITHIN: H* EDGE OF PAVEMENT TEXTURAL CLASS: 1 ASSESSOR'S MAP 165 PARCEL 10 0 Cl) Cl) 0 10 OWNER OF RECORD: GLENN & LAURA HOFFMAN N88046'20"E z 0 < ADDRESS: 31 GINGER LANE 110.00, on 47.00' Loamy Sand OSTERVILLE, MA 02655 0 A 1 OYr 3/2 • 100 46.17' LL. 40 0 B Loamy Sand FEMA FLOOD ZONE C Cr 0 1 OYr 5/6 COMMUNITY PANEL# 2500010016 D > 46 BIT. DRIVE 44.17' 34" 17. DEED REFERENCE: L.C.C. 167283 0 Perc MAP 165 52" 42.67'• 18. PLAN REFERENCE: L.C. PLAN 30384-B PARCEL 10 0 12,110 S.F.± 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. 0 -z" 0 :% 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY 0 • East B- FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY x Medium Sand FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. M 0 1> WALK C 2.5Y 6/3 3 21. IN ACCORDANCE WITH 310 CMR 15.401 - 15.404, THE FOLLOWING LOCAL UPGRADE 0- Cl- APPROVAL IS REQUESTED FROM 310 CMR 15.211: MAP 165 1.) A 3.8-VARIANCE(20.0'- 162)FOR THE SETBACK FROM THE PROPOSED LEACHING PARCEL11 LOCUS PLAN_ FACILITY TO THE FOUNDATION. cn SCALE: 1 1000' 126" 36.50' No Mottling, Standing or Weeping Observed DESIGN DATA TEST PIT DATA LEGEND 1> 0 PERC No. 12513 U) NUMBER OF BEDROOMS(DESIGN) 3 INSPECTOR: Donna Z. Miorandi, R.S. 50x0 EXISTING SPOT GRADE CA C) EVALUATOR: Bradley Bertolo, E.I.T. - - - 50 - - - EXISTING CONTOUR z 0 W 11 DESIGN FLOW 110 GAUDAY/BEDROOM 6 C2 C.S.E.APPROVAL DATE: July 2003 o CA) [11 #31 i TOTAL DESIGN FLOW 330 GAUDAY -EK1- PROPOSED CONTOUR 02 31 0 rfl DATE: March 30, 2009 -4 EXISTING DESIGN FLOW X 200 % 660 GAUDAY O/H/W - EXISTING OVER-HEAD UTILITIES 3-BEDROOM TEST PIT#: 2 DWELLING ELEV TOP= 47.00'USE EXISTING 1,000 GALLON SEPTIC TANK GAS EXISTING GAS LINE TOF =47.2'± ELEV WATER= <36.50' W-W EXISTING WATER LINE TEST PIT LOCATION 47xO-X-X-X- --HC-2 MAP 165 INSTALL 12 - ARC 36HC (#3616BD) BIODIFFUSERS PERC RATE EXISTING 1,000 GALLON SEPTIC TANK 1 X-X-X- - PARCEL DEPTH OF PERC X X-X-X SYSTEM CAPACITY TEXTURAL CLASS: 1 PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE PROPOSED 40 MIL. IMPERVIOUS GEOMEMBRANE LINER X1 0 I 46x7 (TOTAL L.F.OF BIODIFFUSERS)(7.8 SF/LF)(0.74 GPD/SQ.FT.)= GPD 0 PROPOSED DISTRIBUTION BOX PROPOSED INSPECTION PORT WITH x 1-� GAE GAS DECK (60.0')(7.8 SF/LF)(0.74 GAUSQ.FT.)= 346.3 GAL. LEACHING DAY A 0.. Loamy Sand 47.00' PROPOSED ARC 36HC(#36166D) BIODIFFUSER I OYr 3/2 ACCESS BOX TO GRADE (TYP OF 2) F4-607 C-1 TOTALS: 1 - - 10" Loamy Sand 46.17' x 3) , 30.0' (4 F4 6-771 B 1 OYr 5/6 TOTAL NUMBER OF BIODIFFUSERS: 12 34 44.17' Benchmark TOTAL NUMBER OF COUPLINGS: 0 Nail in Tree X1 TOTAL LEACHING AREA: 468.0 SQ.FT. Elevation =48.00' Cn TP1 TF�2" 0 0 46x6 TOTAL LEACHING CAPACITY: 346.3 GAL./DAY REV. BY APP'D._ _ I_ _ _____ DESCRIPTION Aivrox. M.S.L. C" 47.00-1 00, --DGUf�LANDSCAPE AREA I I I -- %, �- E _ `7 PROPOSED SEPTIC SYSTEM UPGRADE (2 0- 1 -,rI /-A - PREPARED FOR: X - rly F4 6=x=5r I)' I- r4-6751 NOTE: I- C Medium Sand GLENN & LAURA HOFFMAN x EFFECTIVE LEACHING AREA OF 7.80 SF/LF OBTAINED FROM THE 2.5Y 6/3 DEPARTMENT OF ENVIRONMENTAL PROTECTION APPROVAL LETTER S88046'20'W "MODIFIED CERTIFICATION FOR GENERAL USE" ISSUED TO LOCATED AT 46x4 46x3 110.00, ADVANCED DRAINAGE SYSTEMS, INC. ON OCTOBER 3, 2003(LAST -- I MODIFIED JULY 23, 2008). TRANSMITTAL NUMBER=W000052. 31 GINGER LANE PROPOSED TOTAL 12 ARC 36HC BIODIFFUSERS -APPROXIMATE LOCATION OF EXISTING \-EXISTING 1000 GALLON SEPTIC TANK TO CEN T.E RV I-LLE-, MA SOIL ABSORPTION SYSTEM (3 GALLIES) BE UTILIZED AS PART OF THIS DESIGN (6 BIODIFFUSERS EACH TRENCH)J TO BE REMOVED AND REPLACED WITH 126"1 36.50' SCALE: 1 INCH = 10 FT. DATE: APRIL 22, 2009 SWING-TIES 1 0 10 20 40 80 FEET CLEAN COARSE SAND \-APPROXIMATE LOCATION OF EXISTING No Mottling, Standing or Weeping Observed DESCRIPTION HC-1 HC-2 DISTRIBUTION BOX TO BE REMOVED JOHN L, PREPARED BY: RESERVED FOR BOARD OF HEALTH USE 0 CHUIC fl,_L BIODIFFUSER CORNER(1) 32.4' 30.7' PROPOSED DISTRIBUTION BOX JC ENGINEERING, INC. LII BIODIFFUSER CORNER(2) 61.3- 32.3' 1 N AL i607 2854 CRANBERRY HIGHWAY BIODIFFUSER CORNER(3) 60.2- 233 EAST WAREHAM, MA 02538 BIODIFFUSER CORNER(4) 30.2- 21.0' SITE PLAN- 508.273.037.7 SCALE: 1"= 10' Drawn By: MCP Designed By:MCP Ctmcked By:JLC JOB No.IW1