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0004 GUNSTOCK ROAD - Health
4 Gunstock Road Ilk= 145 -023 0 FORM3o HOBBS&WARREN,INC. THE COMMONWEALTH OF MASSACHUSETTS . OARD AL .. / Y WN may. ' 6 i o e_'% ARTME A.6 UN-NNItt ADD SS ' <e� H 1 4_ Address V 4C6ff)cs `_�Occ1 p`it o floor Apartment No.' No.of Occupants ' No.of Habitable Rooms No:Sleeping Rooms " No.dwelling or rooming units No.Stories Name and address of owner F Remarks Reg. Via. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: =°' Drainage ' Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst�p.: ❑ B ❑ F ❑ M Doors,Windows: ., RooPf Gutters,Drains: M Walls: Foundation: _ Chimney: BASEMENT Gen.Sanitation: Dampness: < _ Stairs: Lighting: STRUCTURE INT. Hall,Stairwa :j' " Obst'n.: ' Hall, Floor,Wall;'Ceilin Hall-Lighting: ' 'Hall Windows: HEATING Chimneys: . Central ❑Y ❑ N Equip. Repair T ` TYPE: Stacks,Flues,Vents: PLUMBING: Su I :Line: > ❑ MS ❑ ST. ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 0.220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wirin : DWELLING UNIT Ventil. Lgtng. Outlets Walls , eil . Windom Doors RcLpr LQQk, Kitchen Bathroom Pantryy e Den ' Living Room Bedroom 1 = Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil;Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice,Roaches or.Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH"OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED -BY 105CMR 410.750. OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over), ' a "THIS INSPECTION REPORT SIGNED AND CERTIFIED UNDER THE PAINS D PENALTI F PERJURY." 0 Q ' INSPECTOR '< LE T DATE TIME THE NEXT SCHEDULED REINSPECTION l 1 V � P.M. i 410.750:.--ConditionsDeemed to Endanger ,or Impair Health or-Safety _ The following conditions, when 'found to exist-in residential premises, shall be deemed conditions which may endanger or impair the health, or safety , and well-being-of ,a person. or persona occupying the premises. This listing is composed-of theseiitems which arildeemed to always have the potential io endanger ;or-materially impair' the health or safety,. and, well-being-of the opcupantsjor the public. BecausekChapter II,' 105 CMR 410.000 through 410.499 statetAnimum requirementeof fitness for human habitation, any violation has the potential to fall withintthis category; in any given>situation but may not do so in every case and therefore cannot be included in thia; listing • Failure to include shall in no way be.construed as'a determination that other violations may not be found to fall within this category. Nor' shall failure to include affect the duty of the local health official to order repair or correction of the violation(s) pursuant to 410 CMR 410.830 'through 410.833 nor shall it affect the legal obligation of the person to whom the order is issued to comply with such order. _- - (A) Failure to provide a supply of water sufficient.in quantity, pressure " and temperature, both hot and cold, to- meet the ordinary needs of the occupant In accordance with 105. CMR 410.180 and 410.190 for a period of 24 hours or - - longer. - (B) Failure to provide heat as required by-105 CMR 410.201.or-improper venting or use of•a space h;ter or, water heatsr as prohibited by 105 CMR A10.200(B) and 410.202. 1 ;:; r (C) Shut-off and/or failure to restore electricity or•gas. .^(D). Failure to supply the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253(A), 410.253(B) and' the lighting in common area required by •105 CMR 410.254. .(8) Failure to provide a safe supply of water. - (F) _ Failure to provide a toilet and maintain a sewage system in operable - eoedition as required by 105 CMR 410.150(A)(1) and 410.300. (G) Failure to provide adequate exits, or the obstruction of ,any exit, Passageway or common area caused by an object, including .garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450 and 410.451. (H) -Failure to comply with-the security requirements of 105 CMR 4110.480(D). (I). Failure to comply with any provisions of 105 CMR '410.600 through.410.602 . _ _ r6lch.results in any accumulation of garbage, rubbish, filth or other causes 'ot sickness which may provide a food source or harborage for rodents, insects - nor other pests or otherwise contribute to;accidents or. to the creation or spread of disease. - (J) The presence of lead-based' paint on a`dwelling or dwelling'unit in ".violation of the' Massachusetts•Department of Public Health Regualtions for -Lead Poisoning Prevention and Control 105 CMR 460.000. (K) Roof;"foundation, {or other structural Aefects that may expose.-the occupant or;anyone else to. firef, ,burKs, shock, accident or.other dangers ,or . F Limp& sent to health -or dafety (L) Failure to 'install electrical, plumbing, heating and gas-buining facilities in accordance with accepted =plumbing, heating, gas-fitting'and electrical wiring standards or failure to maintain such facilities as are'required by 105 CMR 410.351 and 410.352 so as to expose the occupant. or anyone else to fire, burns, shock, accident-or other danger or impairment' `to: health or safety. (M) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to•or,knowledge of the owner of said condition or conditions: _ lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack 'of a. stove and oven or any -defect that renders either operable. (2) failure to provide a•washbasin and a shower or bathtub-as required - in 105 CMR 410.150(A)(2) and 410.150(A)(3) and any defect which - renders them inoperable. Q) any defect in the electrical, plumbing, or heating system which makes such system or.any part thereof in violation of generally accepted plumbing heating,, gas-fitting, or_electrical,wiring standards that do not create an immediate hazard. (r)- failure to maintain a safe.handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B). (5) failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105'CMR 410.550. (N) , Amy other violation of Chapter II not enumerated in.105 CMR 410.750(A) •through .(M) shall be deemed to be-a condition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time.'so ordered by the board of health... FORM 3o�Ho88s&WARREN,INC. THE COMMONWEALTH OF MASSACHUSE'TTS i i 1 OARD�OF T H A�L . �� { - C Y d" W o © DE ARTMEN 1V � p�,M SVey`e., ADD $$ T EPHONE_,/ Address t �'`� �J JOccupant. Floor Apartment No. No.of Occupants No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units No.Stories Name and address of owner Remarks Reg. Via. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst',@.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall,Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond, Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. Lgtng. Outlets Walls Eeil . Windwj Doors Floors, t gjgk Kitchen Bathroom I I'M Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice,Roaches or Other: s, Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL—BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT ,SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES-0 PERJURY." © C j INSPECTOR i� % � If LE 414AJ 1. r DATE TI EP . A.M. THE NEXT SCHEDULED REINSPECTION ` '► P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing _ is composed of these items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential to fall within this category in any given.situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as.a determination that other violations may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of the violation(s) pursuant to 410 CMR 410.830 through 410.833 nor shall it affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space_heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shut-off and/or failure to restore electricity or gas. (D). Failure to supply the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253(A), 410.253(B) and the lighting in common area required by 105 CHR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage system in operable condition as required by 105 CMR 410.150(A)(1) and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by an object, including garbage or trash, Which prevents egress in case of an emergency 105 CMR 410.450 and 410.451. (H) Failure to comply with the security requirements of 105 CMR 4110.480(D). ; '(I) Failure to comply with any provisions of 105 CMR 410.600 through 410.602 -.'which results in any accumulation of garbage, rubbish, filth or other causes -`of sickness which may provide a food source or harborage for rodents, insects -,,or other pests or otherwise contribute to accidents or to the creation or -....spread of disease. (J) The presence of lead-based paint on a dwelling or dwelling unit in :.violation of the Massachusetts Department of Public Health Regualtions for Lead Poisoning Prevention and Control 105 CMR 460.000. =(R) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or i pafftent to health or dafety. W Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted .plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilities as are required by 105 CMR 410.351 and 410.352 so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment `to:health or safety. QQ Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (t) lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either operable. (2) failure to provide a washbasin and a shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) and any defect which renders them inoperable. (3) any defect in the electrical, plumbing, or heating system which makes such system or any part thereof in violation of generally accepted plumbing heating,, gas-fitting, or electrical wiring standards that do not create an immediate hazard. •(v)_ failure to maintain a safe handrail or .protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B). (5) failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within.the time so ordered by the board of health. { FORM 30'HOBBsB WARREN,INC. THE COMMONWEALTH OF MASSACHUSETTS BOARD, - F HEALTH ` CITY/TOWN W . f 6A " ', ARTME�T� V 11 1 n ADD ESS 5 r7y//�'J�`/�( PIccupant ELEPHONE,,/ IAddress 4 G �/ s_rocY\ iM1t . Floor Apartment No. ' No 1of Occupants No.of Habitable Rooms No.Sleeping Rooms No.dwelling or rooming units No.Stories Name and address of owner Remarks Reg. Vim YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst�.n.:, _ -- ❑ B ❑ F ❑ M Doors,Windows: i Al! ! t C�f1.y`,i Roof U(' 1-#.. YV16 51( /41 Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : W STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: r_ HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Oeils. Windvj Doors Floors, L_ Kitchen l 1i�7.� 11I t`11 M( � ► Bathroom �'' /") , �� ; <= 11 - s I Pantryrn Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice,RoacheS,OrQthou., Egress ' 'Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL—BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND r PENALTIES-OF PERJURY." INSPECTOR !�f'1 ; � _ '/ . 'J "TITLEf DATE �'tr: .U ( 1 �} A:TIME P .1 THE NEXT SCHEDULED REINSPECTION t ' ter" a A.M.P.M. 410.750:. Conditions 'Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of these items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential to fall within this category in any given situation but may not do so in every case and therefore cannot be included in this listing. - Failure to include shall in no way be construed as.a determination that other violations may not be found to fall within' this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of the violation(s) pursuant to 410 CMR 410.830 through 410833' nor shall it affect the legal obligation of the person to whom the order is issued to_comply with such order. (A) Failure 'to provide-a supply of water sufficient in quantity, pressure snd temperature, both hot and cold, to meet the ordinary needs of• the occupant ' in accordance with 105 •CMR-410.180 and 410.190 for a period -of 24 hours or - - longer._ - (B) Failure• to provide heat as required by 105 OiR 410.201 or improper - venting .or use of a space heater or water. heater as prohibited .by 105 CMR _ 410.200(B) and 410.202. (C) Shut-off and/or failure to restore electricity or gas. (D). . Failure to supply the ilectr'ical facilities required'by 105 CMR 410.250(B); - `4 410:251(A),"410.253(A), 410.253(B) and the lighting in common area required - by 105 CMR 410:254. - � -(R) Failure to provide a safe supply•of water.. __(F) _Failure to. provide-a toilet and maintain a sewage system in operable ctiudition, as required by 105-CMR 410.150(A)(1) and 410.300. '(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by an object, including garbage or trash, Which prevents egress in case of an emergency 105 CMR 410.450 and .410.451. (H) -Failure to comply with the security requirements of 105 CMR 41b.480(D). '. (1) . Failure to comply with any provisions of 105 CMR 410.600 through 410.602 „ vbich.results in any accumulation of garbage, rubbish, filth or other causes "'it sickness which may provide a food source or harborage for rodents, insects �ior other pests or otherwise contribute to accidents or to the creation or -.-.spread of disease. (J) The presence of lead-based paint on a dwelling or dwelling unit in ;violation of the Massachusetts Department of Public Health Regualtions for - Lesd Poisoning-Prevention and Control 105 CMR 460.000. foundation, or +other structural-defects that may expose the occupant or anyone else to fire,.burns,. shock, accident or other dangers or I*Attftnt to health -or dafety. (L) Failure'.io install electrical, plumbing, heating and gas-burning facilities in accordance with accepted .plumbing, heating, gas-fitting and electrical wiring standards or failure 'to maintain such facilities as ~ - are'Tequired by 105 CMR 410.351 and 410.352 so as to expose the occupant or- anyone else-to fire, burns, shock, accident or other danger or impairment - _-_ ._to:health or safety. - � `-(H) Any of the following conditions which remain uncorrected for a period - _ _of five or more days following- the notice to.or knowledge of the owner of said condition or conditions: of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack 'of a. stove and oven or any defect that renders either operable. (2) failure to provide -a washbasin and a shower or bathtub as- required in 105 CMR 410.150(A)(2) and 410.150(A)(3) and any defect which renders them inoperable. Q) any defect in the electrical, plumbing, or heating system which makes +t such system or-any part thereof in violation of generally accepted plumbing heating,, gas--fitting, or electrical wiring standards that do not create an immediate-hazard. (r) •failure to maintain a safe handrail or .protective railing for every ,siairway, -porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B). (5) failure to eliminate rodents, cockroaches, insect 'infestations and other pests as required by 105 CMR 410.550. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the board of health. TOWN OF BARNSTABLE LOCATION SEWAGE # 1CV0 i VILLAGE 436E-60_,v<c(& ASSESSOR'S MAP & LOT( INSTALLER'S NAME&PHONE NO. i,�ry<�vy SEPTIC TANK CAPACITY 1: c�c� LEACHING FACILITY: (size) ;k .15X f NO. OF BEDROOMS a o BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: 4t I�quO06 Separation Disiance 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 i o - - Health Complaints 24-Mar-98 Time: 1:30:00 PM Date: 3/20/98 Complaint Number: 1243 Referred To: DONNA MIORANDI Taken By: DONNA MIORANDI Complaint Type: CHAPTER II HOUSING Article X Detail: Business Name: Number: 4 Street: Gunstock Road Village: OSTERVILLE Assessors Map_Parcel: i Complaint Description: Windows leak-not tight. Senior citizen on social security with electric heat that is 400-500 dollars per month. Actions Taken/Results: Investigation Date: Investigation Time: 1 PAR ] Real Estate System - General Property Inquiry] Help [ ] Parcel Id': 145 023- - Account No: 80584 Parent: l Location: 4 GUNSTOCK RD OST Neighborhood: 29AC Fire Dist: CO Devel Lot: 72 Lot Size: .36 Acres Current Own: PHILLIPS, JERRY J State Class: 101 9 WOOD FALL RD No. Bldgs: 1 Area: 1612 Year Added: MEDFIELD MA 2052 Deed Date: 120184 Reference: 4370/216 January 1st: PHILLIPS, JERRY J Deed MMDD: 1284 Deed Ref: 4370/216 Comments: Values: Land: 34000 Buildings: 75900 Extra Features: Road System: 4 Index: 642 (GUNSTOCK ROAD ) Frntg: 104 Index: 1146 (OLD EAST OSTERVILLE ROAD ) Frntg: 145 Control Info: Last Auto Upd: 050695 Status: C Last TACS Update: 060888 Land Reviewed By: Date: 0000 Bldgs Reviewed By: Date: 0000 Tax Title: Account: Taken: Account Status: Hold, Status: Cancel [ ] Press XMT for more data Next screen [PAR ] Action [ ] Owners Name [ ] Road Index [ ] Road Name, [ Parcel Number [ 145] [024] V 7 l .L..t..-'.1i- � i .f 3 :s;ri rlr` 1 ! r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION _CT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION #A Property Address: 4 Gunstock Road � C Osterville. Owner's Name: _ Priscilla Phillips Owner's Address: Date of Inspection: Name of Inspector:(please print) v ' P ) S P son r William _ •Robin l _ r Company Name: William E. Robinson Septic Service - MailingAddress: P 0 Box 1089 Centerville, MA Telephone Number: ( 508) 775-8776 xs CERTIFICATION STATEMENT d y 1 certify that I have personally inspected the sewage disposal system at this address and that the info ation re brted W below is true,accurate and complete as of the time of the inspection.The inspection was performed b ed on rM, training and experience in the proper function d maintenance of on site sewage disposal systems.1 m a DEP approved system inspector pursuant to S ion 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: z t , ..�. Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health of DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies;sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under.the same or different conditions of use. Title S Insp ection Form 6/152000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4 Gunstock Ro ad Ostervi.11e Owner: Priscilla Phillips Date of Inspection: 1 —6- Ir--p 5"' Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. 71 ' Passes: ave 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. stem Conditionally Passes: ne or more system components as described in the"Conditional Pass.'section need to be replaced or repaired The-system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer es,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. Th septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, xhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing t nk 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 indicaten that the tank is less than 20 years old is available. ND expl in: bservation of sewage backup or break out or high static water level in the distribution box due tabroken or _ obstru ed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with appro al of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND exp in: e system required pumping more than 4 times a year due-to broken or obswucted pipe(s).The system will pass insp tion if(with approval of the Board of Health): broken pipe(s)are replaced obsbuction is rttmovcd ; F, ND explai I �A Page 3 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4 Gunstock Road f Osterville Owner: Priscilla Phillips Date of Inspection:9. 2-6 5'" 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 ailing to protect public health,safety or the environment. 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 sys gem is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. — The system has a septic.tank and SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. - The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more fronl a private water supply well— Method used to determine distance 'This system passes if the well water analysis,performed at a DEP certified-laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and - the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. . 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4 Gunstock Road Osterville Owner: Priscilla Phillips Date of Inspection: D. Sys em Failure Criteria applicable to all systems: You mu t indicate"yes"or"no"to each of the following for all inspections: Yes N 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'Is 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 I00.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 f^_et from a private uatrr 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 P Y e P 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. Large Systems: - To be considered a large system the system must serve a facility with a design nowof 10,000 gpd to 15,000 f;Pd• You must indicate either"yes"or"no"to each of the following: (71te following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well 1 you have answered"yes"to any question in Section E the system is considered a significant threat,or answered •.-cs"in Section D above the large system has failed.Tlx uAmer or operator of arty large system considered a s gnificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR r5.304.The system owner should contact the appropriate regional office of the Department. 1 4 Page S of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST - Property Address: 4 Gu-nstock Road Osterville Owner: Priscilla EhilUps Dale of inspection: Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No/ PP mping information was provided by the owner,occupant,or Board of Health ✓ Were any of the s stem�com"onents pumped out'Y P p p ut the previous two weeks? Has the system received normal flows in the previous two week period? 1✓ Have large volumes of water been introduced to the system recently or as part of this inspection 7. ✓ _ 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? L� t: 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 P p o condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? — _ as the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? 71c size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. _ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) 5 Page 6 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 4 Gunstock Road Osterville - Owner: Priscilla Phillips Date of Inspection: I FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):- Number of current residents: Does residence have a garbage grinder(yes or no): -o Is laundry on a separate sewage system(yes or no):,L,�o[if yes separate inspection required] Laundry system inspected Ives or no):4 6 Seasonal use:(yes or no): 0 Water meter readings,if available(last 2 years usage(gpd)): 2004 — 48, 000 Sump pump(yes or no):/t� 2003 — 44, 000 Last date of occupancy:�o e COMMERCIA USTRIAL Type of establis ent: Design flow(b ed on 310 CMR 15.203): gpd Basis of desi flow(seats/persons/sgft,etc.): Grease trap esent(yes or no):_ Industrial w ste holding tank present(yes or no):_ Non-sani waste discharged to the Title S system(yes or no):_ Water m ter readings,if available: Last da of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 0 6" Y-) Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP F 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: 7- C' Were sewage odors detected when arriving at the site(yes or no): 6 f Page 7 of I OFFICIAL INSPECTION FOI01—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F0101 PART C ' SYSTEM INFORII2ATION(continued) Property Address: 4 Gunstock Road Ostervi e ' Owner: Priscilla P i fps Dale of InspecIIon. -- �-8 BUILDING SEw (locate on site plait) Depdt below gra : Materials of co struclion:_cast iron _40 PVC_other(explau►): Distance Got private water supply well or suction linc Comments( rt condition of jou►ls,venting,evidence of leakage,etc.): SEPTIC TANK:`(locate on site plait) Depth below grade: l / Material of construction: cioncrcte metal fiberglass nolycthylene _othcr(explain) — — . If tank is metal list age:_ Is age confirmed-by a Certificate of Compliance(yes or no): certificate) —(attach a copy of e Dimensions: Sludge depth: ' ' Distance Gom lop of slud�c`10 bQttottt of outlet Ice or banfc: Scum thickness: f�� , 1 Distance from lop of stunt to lop of outlet Ice or bafnc'. - Distancc Gorn bottom of scum to bottom of tict Ice or banlc: � I low were dimensions determined: ry- n 3 Comments(on pumping recommendations,inlet and outlet tee or banle conditicn,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): % 7` & _1 /c J • GREASE TRAP:_(local on site plan) - Dcp1h below grade:_` Material of construction.—concrete metal fiberglass_polycdlylene—other (explain): — — Dimensions: . Scum Ihickncss: Distance from top f scum►o top of outlet tee or baffle: Distance front be onn of scum to bottom of outlet tee or baffle: Date of last pun ing: COI11r11cnts(o pumping recommendations,utlel and outlet Ice or baffle conditio;►,structural integrity,liquid levels as related to ullet invert,evidence of leakage,etc.): • 7 ,age 8 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F0101 , PART C SYSTEM INFORAIATION(continued) Properly Address: 4 Gunstock Road ftterville Owner:. Priscilla Phillips Dale of Impecllon: TIGIIT or 11OLDIN TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of const Ilion: concrete_metal_fiberglass_polyethylene other(explain): Dimensions: Capacity: allons Design Flow: gallons/day Alann prescn (yes or no): Alarm level: Alann in working order(yes or no):— Date of last umping: Comment condition of alann and float switches,ctc.): DISTKIBUTION BOX:_"(if present must be o pcned locate on site Ian 1 )( plan) Depth of liquid level above outlet invert:� Conuncnts note '( if box is level and Distribution to outlets equal,an),evidence of solids cat over any evid ence of leakage into or out of box,ctc.): / I'UMP CHAMD (locate on site plan) Pumps in wor tng order(yes or no):— A!.amis in w rking order(yes or no):_ Ganunents note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9ofIi r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4 Gunstock Road Osterville Owner: Priscilla Phiili s Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation'not required) If SAS not located explain why: Type ching pits,number:_ leaching chambers,number: :2-- leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): It I I CESSPOOLS: (cesspool m t be pumped as part of inspection)(locate on site plan) Number and configuration: _ Depth—top of liquid to inle vert: ' Depth of solids layer: Depth of scum layer: r Dimensions of cesspo Materials of cons tion: Indication of grow ro dwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on sit Ian) Materials of constructio Dimensions: Depth of solids: Comments(note c dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 l Page 10 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4 Gunstock Road Osterville Owner: Priscilla Phillips Date of Inspection: —� 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. GI . G � 6!— b Ul S� 00 ' 10 Page I I of I I OFFICIAL INSPECTION FOILM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:4 Gunstock Road Osterville Owner. Pri 11 Phillips Date.of Inspection: -4 —6 5 SITE EXAM = _ - Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) ✓✓Accessed USGS database-explain: You must describe how you established the high ground water ele ati n: L - 45 0 11 COMMONWEALTH OR MASSACMUSETTS / L'rXEGUTM OFFICE OF ENVIRONNM4 AL AFF DEPARTMENT OF ENVIRONMENTAL PROTECTION I TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address. • 4 Gunstock Road Osterville Owner's Name: Louis Gial otti Owner's Address: C ! C3 Date of Inspection: '7/03 2eE-2 - ry Name of Inspector:(please print) Sean Jones `" _ _ Company Name: William E. Robinson Septic Service Mailing Address. P ® Box 1089 Centerville, IAA 4 t~ Telephone Number. (501I) 775-11776 O CERTIFICATION STATEMENT i cenify that 1 have personally inspected the sewage disposal system at this address and that the information repotted 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 ma+rdenance of on site sewage disposal systems_1 am a DEP approved system inspector pursuant to ZS " 15.340 o(Titte S(3110 CKR IS.M)- The system: t Conditionally,rasses lr Needs Further valatation by the Local Approving Authority Faits Inspector's Sigi*iaturre: The system inspector shall submit a copy of this inspection repo.-t to the Approving Authority(Board of Heamhvt DEP)within 30 days of completing this inspeetion-N the system is a shared system Of has a design flow of I0,000 gpd or greater,the inspector and the system owner shall sulrnnk the report to the appropriate regional office of the DEP.The original should be sent to the system Owner and co ies sent to the buyer,if applicable,and the approving authority. Notes and Comments `•"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the systecm will perform in the future under the same or different conditions of use. Title 5 Inspection form 6115/2000 page I Page 2 of I 1 r � OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFTCATION(continued) Property Addms: 4 Gunstock Road Osterville Owner. Louis Gi Iiotti Date of Inspection: a3�. Inspection Summary: Check A,B,C,D or E I ALWAYS complete all of Section D A. System Passes: i have not found any information which iRdicatestbal any Of tht fialmecrilefia described,in;10 CMR 15.303 or in 310 ClAR 15.304 exist Any fm'lure at"nsa evaluated are indicated below_ Comments: B. system Conditionally Passes: M- One or more system components as descn-bed in the-Conditional Pass"section teed to be replaced or repaired_The system,upon completion of the replacement or repair,as approved by the Board of Healilt,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If'!not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfdtmtion or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. •A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distri b:ui w box due twbroken or obstructed pipe(s)or due to a broken,settled or tntt v=dbuiibu3ion bm System vvtll pass inspection if(with approval of Board of Health): broken pap (s)are replaced obstntrfion is mmoved distribuflon box is leveled or aeplaccd ND explain: "the system required pumping more than 4 boles a year dice to broken or obsawcd p'rpe(s)_The system will pass inspection if(with approval oftbe Board of Hed&): brokers pipe(s)are nplarcd -obsouctimism ND explain: Page 3 of 1 i OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) . Property Address: 4 Gunstock Road Osterville Owner. Louis G' Date of Inspection: d . C. Further Evaluation is Required by the Board of flealth: Conditions exist which require further evalmdon by the Bird o Health in order to determine if the system is failing to protect public health,safety or the environment 1. System will pass unless Board of Health determines in accordance*ith 310 CrdR 15.303(l)(b)that the, system is not functioning to a manner which will protect public health,safety and thesnvironment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the-public health,safety and environment: . _ The systems has aseptic tank and soil absorption system(SAS)and the SAS is within,100 feet of a surface water supply or tributary to a surfact water supply_ — She system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more froni a private water supply well" Method used tat determite distaatce '*This system passes if the well water analysis,performed at a DEP ceitifwd laboratory,for colifortn bacteria and volatile organic compounds indicates that the well is frcc 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 analysis must be attached to this form_ i, l/ther: r , 3 Page 4 of I t r , OFFICIAL INSPECTION(FORM—NOT FOR VOI.UNTICARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 4 Gunstock Road Osterville Owner.• Louis Glgliotti Date of Inspection: 7 D. System Failure Criteria applicable to all systems: You must indicate"y&'or"no"to each of the following for awl inspections: Yes 7- Backup of sewage into facility or system comlonew date to overloaded or clogged SAS or cesspool Discharge or ponding of eflkwat to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution lox above.oudet invert slue to an overloaded or clogged SAS or cesspool w invest available volume is less than day flow Liquid depth in cesspool is Less than 6"below trt.eft or it t � y Required pumping more than 4 times in the last year I OT due to clogged or obstructed pipe(s).Number oftimes 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 I ofa public well_ _ Any portion of a cesspool or privy is within 50 feet of private water supply well. .,An poi of a cesspool or is less than 100 feet but greater than 50 feet from a private%.miff y po Pr3' supply well with no acceptable water quality analysis-[This system passes if the tsell water analysis, performed at a DEP certified laboratory,for coliferm 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 fro other failure criteria are triggered.A copy of the analysis must be attached to this form.l ' NO (Yes/No)The system fails.i have determined that one or more ofthe above failure criteria exist as described in 3l0 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 faiilure. E. Large Systems: N To be considered a large sy cm the system trust serge a facility with a design flow of I0,M gpd to 15,9011 gpd- You must indicate either"-yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply— the system is located in a nitrogen sensitive mica(latcrim Wellhead Protection Area-11NPA)or a mapped Zone 11 of a public water supply well I f you have answered"yes"to any question in Sesfm E the system is considered a significant unreal,or miswcrcd "yes"in Section D above the large system bas fnled.The 9--mm or operator of army large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15-304.The system o t ner should contact the appropriate rcgianal office of the Department. 4 Page 5 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART I3 ' CHECKLIST Property Address: 4 Gunstock Road Osterville Owner: Louis Gialiotti _ Date of Inspection: Check if the following have been done.You roust indicate or"no"as to each ofthe following: Yes o , mping information was provided by the owner,occupant,or Board of Health V Were of the system components d out in the previous two weeks? — —/ �y Y Po pub Has the system received noraW flows m the previous two%v&peed? Have a volumes of water been in to the system reed or as of this' ' on? � s3's y twat utspeda . ;✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) i/ Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out? t✓ Were all system components,excluding the SAS,located on site? _tx�_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected foi the condition of the af6les or tees,material of construction,dimensions.depth of liquid,depth of sludge and depth of sewn? _ Was the facility owner and occupants if different from owner provided with information on the proper — tY ( l� )l� 9 per maintenance of subsurface sewage disposal systems? - The s' and ion of the d Absorption System S ca the site has been determined based one size location So at► ys ( A5� _ Yes o 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)1310 CMR 15.302(3)(b)] S Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 4 Gunstock Road Osterville Owner. Louis Giciliotti Date of Inspection:_ 7 a-3 FLOW CONDMONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(ash): DESIGN flow based on 310 CMR 15203(for examples 110 gpd x 8 of bedrooms): ° Number of current residents. t% Does residence have a garbage g (yes or taoj: Is laundry on a separate sewage system�, �or no):�� (ifyes separate inspection requir'eQ Laundry system inspected(yes or n4=_�A Seasonal use:(yes or no): -t Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 6 — 4,0 0 0 Sump pump(yes or no):_WD 2005 — 9,000 Last date of ooatpancy: 6cc> COMMERCIALRNDUSTRIAL /\f Type of establishment: Design flow(based on 310 CMR 15203): gpd Basis of design flow(seatsfpersortsf gq etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available. . Last date of occupancyluse: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes-or no): If yes,volume pumped:=gallons--How was quantity pumped determined? Reason for pumping: --- TYPYOF SYSTEM /Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool _Privy Shared system(yes or no)(if yes,attack previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the ctin=t 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 Cif known)and source of infortmatton: Were sewage odors daccted when arriving at the site(yes or no):IVC" 6 Page 7 of 1 I OFFICIAL INSPECTION FORM—PLOT FOR VOLUNTARY ASSESSAIENTS SUBSURFACE SELVAGE DISPOSAL SYSTEM INSPECTION FORM PART C , " Sl'S"I'EINi INFORMATION(continued) Property Address: 4 Gunstock Road s ervi e Owner: Louis Gigliotti Date of inspection: /a,� 3> BUILDING SEWER(locate on site plan) Dcpdi below grade:„ Malerials of construction:_cast iron +�Q PVC other(explain): Distance from private water supply wcfi or suction line: Comments(on condition of joints,venting,evidence of kakage,etc.): ' SEPTIC TANK:(locate on site plan) r Depth below grade: � Material of construction:vEoacrctc!metal fiberglass_polyctlsylene t. _othcr(explain) If tank is metal list age:_ Is age confirmeitb}a Certificate ofCompliarrce(yes or nu):_(attach a copy of certificate) Dimensions:_ l cm.-t> Sludge depth: ln'` Distance from top of sludge to butiom of outlet tcc or baf c: S Scuni thickness: c> Distance from top of scum to top of outlet tee or bathe: Distance Gorn bottom of seuni to bottom of outlet tee or bafllc: How were dimensions determined. r—>PmeJ Comments(on pumping mentmendations,inlet avid outiet tee or bathe eonditicn,structwal•integrity,liquid levels as feiated to outlj(invert,evidence of leakage,ctc.). G REASE TRAP: (c alc on site plan) Dcpth below grade:_ Niatcrial of construction:`concrete_metal—fiberglass—�__iolyctlt}lcrtc other (explain): Dimensions: Scum thickness: Distance from top of scum to Ioln of outlet tee or battle: Distance from bottom of scum to bottom of outlet tee or baffle: Datc of last pumping: Conunents(on pumping reeonunetndations,inlet and oulki ice or bathe ccutdiliu:►,structural integrity,liquid levels as related to oullc(invert,evidence of leakage,etc"): 7 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART C SYSTEM INFOIM-IATION(continued) )perty Address: 4 Gunstock Road s ervi e rncr: Louis Gigliotti le or Inspection: 7 G1lT or HOLDING TANK: (tank must be pumped at cunt of inspection)(locate on site plan) :pth below grade: aterial of construction: concrete metal fiberglass_polyethyltne other(explain): imensioats: epaeit): gallons csign Flow: gallonsiday lann prescnt(yes or no): larm level: Alarm in working order(yes or no): ate of last pumping: otntnents(condition oralann and float switches,ctc.): )15TIUBUTION BOX: " vprescnt must be opencd)(locate on silt plan) )cpth of liquid level above outlet invert: :onuncnts(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of caka c into or out of box,etc.): •--ems 1zv Y g i a-,t PUMP CHAMBER.��ocatc on site plan) Pumps in working order(ycs or no): Alarms in working order(yes or no):_ Conuncnts(note condition of pump chamber,cundition of putups and appoitenances.etc.): Page 9 of 1 I ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4 Gunstock Road , s ervi e Owner. Louis Gigliotti Date of Inspection: 3 � SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why. Type - leaching pits,number:✓leaching chambers,numbe_r. (� leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovativetaltemative system Typellname of tec hriology_ Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): 5."t c C,•�..s d� �' v�g a f - .��r tiolr+�1. &'4 hyd'a"hc CESSPOOLS:�Af—cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool Materials of construction. Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.). 1� A PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of-solids: Comments(note condition of soil,signs of hydraulic failure,level of pond-Ing.condition of vegetation,etc.): 9 Page 1 Q of i I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 4 Gunstock Road s ervl e Owner: Louis 7-1 10tt1 Date of Inspection: a � SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system excluding tees to at least two permanent reference landmarks or benchmarks.Locate all welts within 100 feet Locate where public water supply enters the building. pel�L OP 13 3° 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART C SYSTEM INFORMATION(,coatu►ued) Property Address: 4 Gunstock Road Osterville Owner. Louis GiglM14267 Date of Inspection: _ SITE EXAM Slope Surtace water Check cellar Shallow wells . Estimated depth to ground water S feet Please indicate(check)all methods used to determine the W&ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed:- Observed site(abutting property/observation hole mutin 151D 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: Orr-�r �� ��-r�tS�t� rY'lb e�L•�e`�e r �AZ'�Y7.nf N G� 11 Town of Barnstable OF THE 1p� Regulatory Services ,SzaB . ; Thomas F. Geiler,Director Mass. t 039. Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report;this Division does not warrantythe functionality of the septic stem in the future Y re p Y nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. r R. - TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION f Date ��' ( 0 Time: In / ' 3 6 Out I -1 CJ _5 Owner 4'�" nant / C Address Address \ Compliance Remarks or Regulation# Yes O Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities I , 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal to - 17.Temporary Housing 18. Driveway Width 19. Number of Tenants Observed 1 a l l a PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) 5 �"-- Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here No................_. ..L....�...... THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH ...........OF...... 1�V. 4 . ...............•- Appliration for Uiiiposal Works Tunutrartiun ramit Application is hereby made for a Permit to Construct kk_� or Repair ( ) an Individual Sewage Disposal System at /eak 114,/1/r� �L-acation-Addres r N . .. •• i Owner . ..................------. Installer Address ��-- U Type of Building Size Lot.. ', ....Sq. feet a Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons.........2__--7....... Showers ( Cafeteria ( ) Q' Other fixtures .--•---...-•-•-•-_•-•••----•-•-_•-•..........--•--•--•.-••................••-••---•- d W Design Flow............................................gallons per person per, day. Total daily flow..................•......................._.gallons. WSeptic Tank--Liquid"capacity............gallons 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 t ) j � '-' Percolation Test Results Performed by.......� � 1-- 1..:_._ .f2V..L�-(.'usDate. A0 aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch' Depth of Test Pit.................... Depth to ground water........................ P.' O Description of oil..© L0-hN..E.S..0 0-ij..---. - ........... ....... N'-�....... L ............�b------------------------------------------------------•-------- 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 TITLE:. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en ed by the,bo o lth. j gg��aa Signed .......--- Date Application Approved By............�G � ................................... ........ Date Application Disapproved for the following reasons--------------------------------------------•------------------------------------------......................... ..........................................:.....•---•--....-•---_--•-•--•------_••---•'--•-•-••-•-•--_•-----•-----•-----•-••----••---•--••-•••----•••----••-•-----_•-•••-•-----•---•-••------••--------- / Date PermitNo......................................................... Issued_.... ---•------------------------- Date i< < :..: No.......... Fps..........................._ THE COMMONWEALTH OF MASSACHUSETTS �--�' BOAR® F HEA TH � f ...................` OF........ .:........ r I.................................................... pliratiun for Uiupuua1 Works Tonstrnriiun ramit Application is hereby made for a Permit to Construct A- or Repair ( ) an Individ wage Disposal Sy tem a ' r., (f-� Pe .. -- -. -- ..-................................... . � -__... - ... finer 7t' ^!� Q"i'✓ °(w'M' rtr f a ....._,__.._._.... .�.. �(.............. .....•-..... -- - ----- { ---•--------. Installer� � Address j�' -�. UType of Building Size Lot_...#_.__I_....._.-•__..._..Sq. feet Dwelling—No. of Bedrooms............................................Expansion tic ( ) C, rbage Grinder ( ) Other—Type T e of Building "� yp g ____________________________ No. of persons.__.__.__.._:_.______._.____ Showers ( — Cafeteria ( ) Otherfixtures -------••--------------------------------............................................... ............................................................. Design Flow............................................gallons per person per day. Total daily flow..............._•:•:.......................gallons. WSeptic Tank—Liquid capacity............gallons 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 �aar -: .--___sq. ft. Other Distribution box ( ) Dosing t��'��� � OJ1V! dCd.�.� c��� ��� a Percolation Test Results Performed by ............................................................. Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ D scri tion of S ------ ---------------------- 2-A _.... .....-1���..� ... �----.�'---•-•....••-- w -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature 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 TITLE 5 of the State Sanitary Code— The undersi ned f rther agrees not to place the syste in operation until a Certificate of Compliance has b ed b the�boa o Ith. Signed---� . ------(--,------- ------------- Date t� Application Approved BY (,. R ............. .-"2 S"- , Date Application Disapproved for the following reasons:............... .........--•--••••••••-•••---•-••---------•-•-••--•-•----•--•-----•---•-•---•--••••-------...•-•-•------J. •---•••--•-•----••-----•----•---•---•------•••------•-------••-••-------•---•-••----•-•----- r Date PermitNo......................................................... Issued._________....._-'_--- Date---•----•- THE COMMONWEALTH OF MASSACHUSETTS BOARD __ HEjA,LT ...` .. ............OF........... ...... ...`.lv. ............................................ C�pr�ifirtt�.� of f�um�fi�nr�e T IS iS TO R IFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by..... t-!!1_� --j_�__'�1�_:=.$ .................................................... �n.. t, at. R In: allyrt¢�"" /07 has been installed in accordance with the provisions of T 1 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.. '.. .___. ........__. dated------- 2 "_- .......... THE ISSUANCE OF THIS CERTIFICATE SWALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Insp ector ............................................ THE COMMONWEALTH OF MASSACHUSETTS OARD O HEA T Diupuua1 murk$ Tunuiriun rrmi# Permission ' ereby granted........................ ,. to ConstrJ r R Dise i ( ) an Indavidu a al s ` Street as shown on the application for Disposal-Works Construction P N A /, ;�",/ :_ ____._ __ .................................. q / Board of Health� DATE. /% ............. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r � r 4 � r rI ; . r t � 1 ,, �r ,a }♦ k 4y' -4�� '-tt ' .`� '+ i •� �,fs �t�,�,'y ,t341�,��,}rt• F� o oE ` 1�• ' }. a '�t +�t" d.,"s�,y{�r1 �, {, it,`1''�'�t rsr l,c S'A,,'3,,, t ��✓• �Q r� 5,.. , r ._1,. t�4'SN, 3,1,, I'iy ;ra` `l r{p fiiPcl '"'�i'11 brt R!. -7 0 .p� ;' ',r a iF:�•��#�• "n� n '�'i. �r' ��1t�,�M`.r:,t,{ �\•+'.. �' � :\ 0 _. �� rS � 4 s �. ••1 �M � r •1 d Jt�y'?�`�.���,`Y�,(�r4r,�'�+ t 1-0 7F h ^v-f;��vdS 1�Q adM•y`'�vr '�' - 'O �-� / `1 rc r�,�.'�-} ttit�'�'�i �-��,a�.?�~ :a�k: TTFF "Qd' a a M * ys"�n +t;`, air S J \tlt w` '+l `fib r 9"'1 n.1 r�qqq��� ,�N7rU` O `C{ .=:°`l`�• /,'' \ ��.� ry +a :',s, ''1�.,}{7•-oS') /i\Fl IA '� `h R +I_rW�,h { �`'�lr� a {�,�'�1'��fP�}YY�i h �, `n � �. 'S/ - ` r� ��r I 'S�G"i�c 7•.°T "� _,A-.•. 33 O - �N - •. :� �( ,` r +`i.. ac'Li "�'`^w •r 72P1,• a i9�' �.r ir a ,,�pd��>�� f, A��,��� r�4 r I c• - , •,��1 , °`� �� df�+'' �# '�'�•7,,,a. .�_' �tF •�'I.'Y�r 6r��•1 D ,Jii�4 .. - 1 1 . � ti`� �,�,yp�'���'„{�� ,I �.}i _i }T c'�"7��,. ••'lii���y�,.�i' .�r� ` �' q +�"'i/.�T,�it.`�+ IF�W^,''fc,tiC � M�, ,�iSS�t f K44 �� ,�'�Aa'�j�.,rf�'�r'Z1�7�4•.' ,0• //i.. 1 iX r•`,r�'� ii'i `T F �•, 2.h.�. yy� Y�r•r' �� Ykl {(YtaV y J, •� 7.9. G.9 ,e '/�•2 �,n r�r�r9s _ ' g R09; ., .O 'Q- .,t`!'i. rd[ �Fi� �. .--.r a: UNSTOC� GOAD. Q ��1 ,� � � Ia,, °k x +, J��. � � •���P'�� 7ri3• ' ' ' . 4s 'y a ff`t.+ik4'ilir r."� R� f`t4ri1_.mt'+'� LEGEND s, ` CERTIFIED PL -:c�eTyNdC:POT ' ELEVATION OAOAl �:.:. t' �XJl �T Nt��,� ",'q"NTOUR - - - p :;_.e.•. s% 1;1 {Iril9MED r' `P,0,T ELEVATION �� c�' �►r�`' 1t1`.� '.. � - - ��`1• S p ZU,!"®OARD Or. nEALTbi p�1 d�},'Cr ►�' 4 �ja �4� , s.n •r FDA' 'E�.s";'{'�` AGENT SCALE � u JrF �. Ep �Ekv ERIG/A/EERIMG CO. IN f,J71 CLIENT . I CERTIFY THAT`??- REGISTERED J08 N0 e!:�.�. - 8UIL13146; SHONIN_t� OPIr LAND CONFORMS 'TO THE„ Z{� 'PN� YLA S .` DR. BY ' c/V E'I1lGINEE-_R§r SURVEYOR OF BARNST BLE. Ir I,s.1-' A,NHSr 7►2 MAIN ST CH. BY �.P .D • // ��,�!y/� ' .�� s,v. � t+ ,04 `YARNlOuNt'MASS. HYANNIS, MASS SHEETZ_ OF D T;E,, ' E 'O r `�r•-y{�.GW�P.?.�--;i�!'1•YY,�..�.Rtii-tc!-a�.�;,y�•iR..�.,�yCY��j�'j•F,y, .. �,....,��.�.� �. y�v�i �+�:., _ � -►'✓w�..nr'.r..�.f. =f�Yra►-^-�" -4 Y - _ - ? ,� .� _ - -N.�.F rY � y _rP ..-/Iii- M?w!iY�r. �•�ar��-�� r - -24 FT._ MIN ' r v, s. flfr?7'8 fF 4F/7' r r� ',47 '7".'.� 'EPTftr 'P�et� ',+QR. 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VM� /� d• 4"CAST `!*LAYER IRON P/PE 0 a v o d o OF /�B -S/B ~'6 I�Ii v.P/TGN 00 0 GAL. ° e I 1 . .- • • o o e o4� �.yASHFD STONE SEPTIC TANK Di.ST e` • . e • • o C BOXAEcr v oI � e • s • • i o°p e :'.:� � ' p ° I '.IEFFEC:T7VC' ' ` •. - 3/a - / /2 v HASHED STDNE d o � I • o • •-.• • II AOoe _ - n u 111 a .O • • • I ► •' Cp n . ° a. e o • • e • • • e o p °•y PRECAST SE.EPAG E IN{/eAT ELEVAT/0N5 a ° o • . . • . . o e e o P/r OR EQU/V. I�.L EV �/a .O. o IV - o a INVERT AT B(J/LD/NG 97. S FT. 6 D/AM. INLET SEPT/C Ti4NK g l' FT f� f7 O/�11►9. C SEE TABULATION OUTLET SEPT/C TANK 9 FT. _ �7 INLET D/STR/BUT/ON BOX 9 FT. SECT/ON OF GROUND WATEQ' TABLE 0U7LETD/57-,q/BtIT/0N BOX 9&,4 =7 INLET LEACHING PIT 9b,O FT .SENlAGE 01 SR4%SA L. .SKS7E1W L EACH11VG =I T TI 5ULAT/ON D.ES/6N CRITERIA SCALE : Y4 _ /[- o" 0J1Vj NS/ON AAFT. I D/HENS/ah' FT. N[`/M®ER OF BEDROOMS .3 GAR®AGEDI5P0-Ml- 41NIT SOIL LOG TOTAL EST/MATED FLOW 3 3 D GA Y SOIL TEST At/ SOIL 7EST#2 S��L TEST NUMBER 00 LEACNING; /^FLLsY• 97 a Al' LA ,DATE OF SOIL TE.S7" � S/OF LPACH/NG PER PIT Y E SQ, FT. of 1 I� BG!TTOM L64CN/Na PER P/T 77F� 0 -Z z' RESULTS WITNESS/?D BY �`H < < S4• Fr s�r'l 6ti AERCOLAT/O/V RRTE jQf/ i e c f NJ/N,//iVCH TOTAL LEACHING AREA �SQ• FT. 5vfd 5011-i ICERCOLA7'10,V RA7-,E RSER1iE LEAC/°//NG AREA ti SQ. FT. ate' cos+ fz A O S J Al V,. T/ , — SA Nv "� - Of/yryss Gr2R✓61 y- �C7-7' V/✓B.T�OC!`- ga 4 / /�M,, :s •�" � $ r���j L->�---� � ?" �.BIJNVIS •(Q-1. ' i �J`.!-�; ._„1 ! 1 �', �, y� l r yf -•d-�.-vr..' - �, •rl '� j� bra '/�a. �t �T y�/ -:.Id0.22162,OY4• `7 8 L�-.; k ` - j•># _ _r` '! r'a•7.� � ,l'`;E ,�i�+-aa �l_ '� hr_ V/fa^ ��'�i 4. �"/'�G-�rIT/��I J •'O-l.f�; S7`. - 3J N0.11IAlK= T' Ei4CC07J/}l�7'LeRE1? HY.sfNN�3 j hl�I.S,S ;u'�`Q. 'ftRMCxTR� .�:s'.s 'a , _ -..:1'. ff -tiff - '. �..r•- ,F y. �Y -_�t� _ �.. tiw � t-." s _ r-� �•j- ;�;' .T.�:-x�'••c-^ :--i�-7.:..- — -..- �' �`C r*- .�:: � r. -.� `+.S .:�1`�'3.=-..,+-ea'�d�a�Y�1-.Vyf7b.�>� ,.�- •.�a'�;`.�� f-�-.. t_ _ '�+f._�:ld TOWN OF BARNSTABLE l;Vo LOCATION 6LW5'f&ek P—prA0 SEWAGE # 2000 HgIA VILLAGE 05 f C-n Jo (& ASSESSOR'S MAP & LOT/ oA3 INSTALLER'S NAME&PHONE NO. R&k'&Sry�SegnkiL "775m8-774 SEPTIC TANK CAPACITY LEACHING FACILITY: ( ) 17it «� (size) �.sz 7lSXlZ NO. OF BEDROOMS ` BUILDER OR OWNER PERMITDATE: 9aa066 COMPLIANCE DATE:glglwaO06 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 �►AC� o L \ 7atck. � p� No. — Li Fee $5 0 uteri THE COMMONWEALTH OF MASSACHUSETTS Entered in com p Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2t phration for �Digooal 6pelem Cottgtruction Permit Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) O Complete System 0 Individual Components Location Address i or Lot No. Owner's Name,Address and Tel.No. Assessor4Map/Yanrceitock Rd. , Osterville Priscilla Phillips 9 Woodfall Rd. , Medfield, MA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) 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 Size of Septic Tank Type of S.A.S. Description of Soil Sand. Nature of Repairs or Alterations(Answer when applicable) Title-5 l e a c h sTs t eM r-_nn G j G t-j n q of a D-box and 2 leach chamberw with stone all around. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo of Health.. / Signed e-Z-1i Date ig,-Aa Application Approved by 5 Date car_) Application Disapproved for the following reasons Permit No. aga2n 9 Date Issued 5 ti (!. No.rJAVFee $5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ,k 01pprfcation for Migogar *p.5tem Construction Permit. Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. Owner's Name Address and Tel.No. 4 Gunstock Rd. , Osterville Priscilla Phillips Assessor'sMap/Parcel 9 Woodfall Rd. , Medfield, MA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.'No. Wm. E. Robinson Septic Service P 0 Box 4089, Centerville Type of Building: Dwelling No.of Bedrooms 3 _ Lot Size sq.ft. Garbage Grinder( ) 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 Size;of Septic Tank Type of S.A.S. t Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consisting of a D-box and 2 leach chamberw with stone all around. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by th' Bo of Health.. / Signed �� V"'� Date o ✓A2 Application Approved by Date g CX_1) Application Disapproved for the following reasons s; f Permit No. — y Date Issued -ff THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Phillips Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( X)Upgraded( ) Abandoned( ')by Wm. E. Robinson Septic Service at 4 Gunstock Rd. , Osteryille has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.oY2— dated Wm. E. Robinson Sr. Installer Designer Al. n G The issuance of this p t hall b be cons d as a guarantee that the s, tem,Wi �ncy @n as de�stgned. �f Date�t � Inspector l J, 1 -----q------------------------- No. L/ Ll Fee $5 0 THE COMMONWEALTH OF MASSACHUSETTS Philli s PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS liopoe a[ *pe;tem Conotruction Permit Permission is hereby granted to Construct( )Repair(X )Uppggrade( )Abandon( ) System stem located at 4 Gunstock Rd. 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. Provided:Construction must be completed within three years of the date of this ermit. Date: Approved by IV, NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTMCATION OF SKETCH AND APPLICATION FOR A DLSPOSAL ' WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) 1, William E. Robinson,5 ,y certify that the application for disposal works construction permit signed by me dated 6—C) , concerning the Property located at 4 Gunstock Rd. , Osterville meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. , The soil is classified CLASS I and the percolation rate is less than or equal to 3 minutes per inch. . There are no within 100 feet of the proposed septic system • There are:no p ' ate:wells within 150 feet of the proposed septic system There is no' tease in flow and/or change in use:proposed •. There no variances requested or needed. ° • The nom of the proposed leaching facility will tit be located less than five feet above the tna ' unt adjusted groundwater table elevation.-f Adjust the groundwater table using the Frimptor m od when applicable) • the S.a.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation,- Please complete the following: A) Top of Ground Sltrface Elevation(using G1S information) _ B) G.W.Elevation +the MAX. High G.W. adjustment DIFFERENCE BETWEEN A and B �-� SIGNED� �t, � :, � DATE: (Sketch proposed plan of system on back). y:health folder:cent v