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HomeMy WebLinkAbout0075 HICKORY HILL CIRCLE - Health 75 ickory Hill Circle ; Osterville NFE ` A = 120 070 e � 4 f d s u r t i 9 SEWAGE INSPECTIONS LOCATION 75 K.ickoa H.i..L>.L/ ia aea DATE 9127103 VILLAGE-Li-f Pauli LP -, Mrj Al, ASSESSOR'S MAP & LOT •INSPECTOR e o-seRh /0. Nacomgea aa. SEPTIC TANK CAPACITY 1000 gaiionz LEACHING FACILITY: (type) I—LP- 1000 (sizc)1500 cats o s NO. OF BEDROOMS 3 BUILDER OR OWNER Nagy Connoa OWNER MAILING ADDRESS Same J 1 .D � �h � � %- ' � � -�h w 7 s' yi c k o� � yiL� c ��- --. T O ATE 9127103 PROPERTY AOORESS: 75_ /1.icko.cy_ K.i.2.0-Ci2cQe- -- --- — — ,• ----------------- On the above date, I inspected the sePtIC Sy-stern-al the above address. Tn,$ system consists of the following: RECEIVED 7. 1- 7000 ga2.Qon .6e/2. .jc tank. 2. 7- 1000 gaieon /aaecazt .beaching /2.i.t. ' OCT 2 12003 Basec on my inspection, I certify the Iollowing condltlons: 3• 7h ie -i,y a tit 2e TOWN OF BARNSTABLE �.ive ze/2t•ic .6y6tem. ( 78 Code) HEALTH DEPT. 4. The 6e/?t.ic zy.etem iz in p4o/2e2 wo2k.ing o/tdea at the /laeeent time. MAP I `Z D 5, Gla�te wate2 ie 48' 9ee0w the .invent /2.i/2e oZ the 2each�ng ?.it. PARCEL. 6. Boaad Rea2th w.i.22 have to dec-ide .il the /140!� ent / OT ...�.. •se/�t.ic 3y.3tem .i,3 iazge enough /o/z a ?give gedAoom hou.6e. SIGNATUR __/-, Noama iy the ,34em would ge a 1500 tan and two 7000 ga2.�on /2it,3. ame _ J L Macomber Jr . company �45t~(zh P_ M�S4mp2C_d_ Son, Inc . . ------------ Cest�cxt '^ one _ _508 . 775_ M8 -- - - - - TnIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. T inks•Cef spooh-Le+chileldo Pumped 6 Init+lled Town Sewer Connections P 0 Box 66 Centerville. MA 02632•0066 115.3338 275.6412 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 j CERTIFICATION Property Address: 75 K.i cko zy K-ie P C iac ee , Owner's Name:hazy onnO/t - Owner's Address: Sarre " Date of Inspection: 9127153 r t Name of Inspector: (please print)joee/2h P. Nacomgea aa. Company Name: 1. P. Ma c o m&a a 9 S.on. in.c. Mailing Address: pn r (A ('on joa)) PPo 4nAA 02632 . Telephone Number: 5Lg_p 7 5_ 3 � 3 8 CERTIFICATION STATEMENT I certify that 1 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 Section15.340 of Title 5(310 CMR 15.000). The system: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails 'Ins ectors Signature:P � Date: The system inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or, DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. t 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. f - Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 75 K.ickoay Ciacie Ohtei%U e, 1°azz. Owner: Nagy Conno/t i Date of inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS-Complete All of Section D A'.G im Passes: ondit.ionaiiy �d I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below, Comments: The ae t.ic 3y.tem ie .in /2aopea woak.iny oadea-7-� .at the 2e.een tme. 'en the ou e. oat B. System Conditionally Passes: !!C,D One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determincd"please explain. 40 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 sepric 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: .111,c/0�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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: , 2 v Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSJPECTION FORM PART A CERTIFICATION(continued) Property Add ress: .75 K..cko4y .�1c22 C�ac2e ' •� e2y.e e, � aye. _ Owner: Ma4y Conn04 Date of Inspection: 9/27103 �.... C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect 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 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. ,()2 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 bu 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: ' 6 3 f Page 4 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 75 H-ickoaV f[.iPQ C./jc.2e. D teaui2Pe, Na.s3. Owner: Nal y Conn.o/t r- Date of Inspection: 9/?7/O 3 D. System Failure Criteria applicable to all systems: r You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface 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 r _ t/ squid depth in,cesspoo is'less than 6"below invert or available volume is less than ''A day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 0 jarty 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. arty portion of a cesspool or privy is within a Zone I of a public well. 1V-tyy portion of a cesspool or privy is within 50 feet of a private water supply well. 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.) _� Condi.t.ionaifty pa�seee (Yes/No)The system Tails. 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 now 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 // vthe 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 — Zthe system is located in a nitrogen sensitive area(l.nterim Wellhead Protection' Area- I 11 WPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page s of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IISPECTION FORM PART B CHECKLIST Property Address: 75 H-ickolty Ki.0 CizcPe e2u a e, a Owner:Ma4u Conno2 ' Date of lospecdon: 9/27/ 3 �.;.. Check if the roll)wing have been done. You must indicate' s"or"no" as to each of the rollowin Yes No Pumpirng information was provided by the owner, occupant, or Board of Health ,_ ezwcrc 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 pan of this inspection ? Were as built plans of the system obtained and examined?(If they were not available note as N/A) z_ 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" luding 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 t maintenance of subsurface sewage disposal systems ? he proper 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. Determined in the field(if any of the failure criteria related to Part C is at issue approximation is unacceptable) (310 CMR 15.302(3)(b)) of distance 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: 75 RickOAY K.ii2 C.iltc-ee .6 eltvz e, ash. Owner:Naltu Cortrzolt Date or Inspection: 9127103 'FLOW CONDITIONS RESIDENTIAL Number or bedrooms (dcsigv); 0 Ntunbcr of bedrooms (actual): .'d�',`+ DESIGN now based on 310 CM3 15.203 ((or example: 110 gpd x 0 orbedrooms).4cw�• Number of current residenu: ---� Does residence have a garbage grinder(yes or no): �d Is laundry on a separate sewage system_ (,yfs or no):;, (if yes separate inspection rcqured) Laundry system inspected (yes or no): Seasonal use: (yes or no): i 5 Water meter readings, if available (last 2 years usage (gpd))?001—32, 000 ga P2o z.a=8 7. 68 gPD Sump pump(yes or no):,W7)-.! �`�/�I� 2002-38, 0 ga•P.PoR.6=104. 1 1 G�'� Last date of occupancy: �a !(�L COMM E R C 1A L/IND U STR1A L Type oresublishment: Design now(hued on 316 C1+M 1.5.203): d Buis of design now(seats/penons/sgft,ete.): Grease osp present(yes or no): L� Industrial waste holding Lank present (yes or no): Non•saniury waste discharged to the Title 5 syste (yes or no): t Water,meter readings, if available. ) Last date 6f occupancy/use: OTHER(describe): Pu GENERAL INFORMATION rtipinQ Records Souicc of information: Not aua.i.Pag-Pe Wu system pumped as pan of the inspection(yes or no):dip If yes, volume pumped:_(Q_gallons •• How was quantity pumped determined? ,4/0 Rcuon for pumping: �TY E OF SYSTEM Scptic unl- d+i-+bw*n-bar.'soil absorption system ,t/D Single cesspool 4 Overflow cesspool Privy Sha.rcd system(yes or no)(if yes, attach previous inspection records, if any) Innovative/Altcrnativc technology. Aruch a copy or the current operation and maintenance c obtained from system owner) ontract (to be Tight unk le Atucb a copy of the DEP approval 1:0Other(describe): J)11 Appr ximate age of ail o ponents, d e stalled (if wn) and source of information: Were sewage odors detected when arriving at the site (yes or no): .! 6 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) . Property Address75 KLckoay Ki22 C.iacPe e2v4 e, 71 a SIT. Owner: Malitl Conn02 Date of Inspection: r.: BUILDING SEWER (locate on site plan) h-- ---`� 4 / 4 0/tanyegeag 12.il2e 9 >—itt ng,6 Depth below grade: thaou yh out the 3 y'6t em' Materials or construction: _cut iron.v040 PVC otther(explain�a,6t i/ton house out. Distance from private water supply well or suction line: //% m Comments(on condition of joinu, venting, evidence of leaks e, etc.): points apneaa .tight, No evidence o� Peakage. The :system iz vented thaou�/y�o�vent.6. ' SEPTIC TANK: y(locate on site plan) l�9hh Depth below grade: Material of construction: oncrete.l.jLmetal.Gb fiberglass,d�polyethylene .Ud othcrtcxplain) /h If tank is metal list age:� Is age confjTned by a Certificate of Compliance (yes or no):L (attach a copy of Dimensions: Sludge depth. Distance from top of to bottom of outlet tee or baffle. _ Scum thickness: Distance from top of scum to top of outlet tee or baffle:_� Distance from bonom of scum to bottom oj outlet tee gr baffle: T ,v How were dimensions determined: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence or leakage, etc.):_- 4 w _ l 'Pumla .the 3,9.12 - r- yak eveffy 2- 3 yea2h In—Pet & out.Pet teee a/ze ig 0„nn f unrzfti4 AniinQ! and .thnh)A no v , nry a T!,Q f��n,�r �c�1 5�[i1C o� eeakage. Liqu-id 2evei at the outlet inve2t t.s 51" GREASE TRAA(�g(locate on site plan) Depth below grade: 4 4 A Material ofconstruction:<concretei�metaW _fiberglassof1, polyethylene4*o the r (explain):_ Dimensions: ,rJA Scum thickness:Avg_ Distance from top of scum to top of outlet tee or baffle: 4,40 Distance from bonom of scum to bottom of outlet tee or baffle: .4/ Date of last pumping: ta —�— Commems (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid IeveLs as related to outlet invert, evidence of leakage, etc.): o n Q A n f 4 Q,Q w 4.0 f��n11 Q iS-Q Q 7 Page 8ofII OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C > SYSTEM INFORMATION(continued) Property Address:75 K.icko2 f[t Ciltc.Pe Oe e2rJ.i Uft, Mazz. Owner:/ azu Conno z Date of inspection: 9/27/03 TIGHT or HOLDING TANKVzX)-e—,(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: _ 1),4 Material of construction: _concrete j2Lmetal&fiberglass jej_polyethylene4i4 other(explain): Dimensions. V Capacity: A14 gallons Design Flow: oil gallons/day Alarm present(yes or no): Alarm level: _X)W Alarm in working order(yes or no): Date of last pumping: Aill, Comments (condition of alarm and float switches, etc.): 71ahi o4 holdlaa tartk.6 aAe not nzeaent DISTRIBUTION BOMkf, (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _AA 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.): 7i.ttalPu lost fox not Pae.6enz PUMP CHAMBEWZIJ (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no):A� Comments (note condition of pump chamber, condition of pumps and appurtenances, etc): l)iimn rhamPyn 1e not 2i{ tvnf Y 8 Page 9 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 75 Kicko/z Iti.2i Cl2C—Pe e ezyc e, a.6.3. Owner:/Maag Connoz Date of Inspection: 91Z7/03 SOIL ABSORPTION SYSTEM (SAS): Zlocate on site plan,excavation not required) _1- 1000 oaiion n2eca•6t ieaeh.ino n-it. If SAS not located explain why: lncrded! Lee 1R T pe leaching pits, number:L ,Q leaching chambers, number: A)o leaching galleries, number: • Alt ]caching trenches, number, length: d 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.): Loamu .3and to medium �.ine .sand. No .3.ignz o e hyd2au.P.ic j?a i..furze oa aoRdinC/ Vo otn}innnpamai, --T CESSPOOLS440C (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: D Depth-top of liquid to inlet invert: Depth of solids layer: _ Depth of scum layer: , Dimensions of cesspool: 14114 Materials of construction: Indication of groundwater inflow(yes or no): 4, Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): roAAtnnnPA nno nn} ARPAPn} PRIVY(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Pni»u 1A not 2/RP.Son}- 9 Page 10 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 75 K.icko2y Hi-Pi Ciacie h e/tvt e, NaT37. Owner: Naa.y C0111101t Date of lospection: Yl=3 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. 1 ' OLb 1 7s y/ k ox y yiLl . 10 Page I 1 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 75 f[tckozy ltiii Cjacje � eatJ.e e, ahh. Owner: (Ma2u Connoa Date of Inspection: 9127103 SITE EXAM Slope Surface water Check cellar Shallow wells t • Estimated depth to ground water feet Please indicate (check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record - If checked,date of design plan reviewed: NA Observed site(abutting property/observation hole within 150 feet of SAS) y�L Checked with local Board of Health-explain: _ N,4 q-&S Checked with local excavators, installers- (attach documentation) Accessed USGSdatabase-explain:htt,?://town a n,6taP2e. MA. CIS. You must describe how you established the high ground water elevation: 'eed: Gahzet 8 M-ii.Pe2 (lode—P. 12/16/94 gaound watea e.Pevat.ionz aPove hea 2eueP. 'zed: CIS 02eeauatcon we PP data 7une 'aed: .[LS Pu 2 tin 92-000- 1 /eaZe 2 ARnua.P nun ea o 2oun watea 1992 Leaching Pit f/ ;cct ZT Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft er. p Fnmpter Method Therefore, the vertical separation distance between the bosom Of the leaching pit and the adjusted groundwater table is feet. , 11 1 ' THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I M A�-C&T-- 7� L DATA 11 13 a n.3 �)F HEALTH �.M 1 ti S 75 Rickolly /jj-Rj Ci/zc_p e 0,3te2ui-e-Pe, Ma.6.3. ............ connoa c 2 r t i f o S Q r) 2d 11 Q Fj I tl Y/ 12 'Cond-itionai—Py r,;i Jill i ch I h"t v e .,c, I L!c fu u r d d j es C. c,v C) r,W) r L U 1 .1 C, y 1, -no "Od .1 n e Xt, 1;7 1 71 1: L gar 09 14 07:58p 1 p. Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Hickory Hill Circle Property Address Mary Connor Owner; Owner's Name Information Is required for every Osterville MA 02655 3-8-14 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way.Please see completeness checklist at the end of the form. , Important:When Wing out forms A. General Information on the�computer, `���� ZN OF Af use only the tab 1. Inspector: `� z�: `•';�y' key to move your v ?��, JAM E S '•N cursor-do not James D. Sears key.use e return Name of Inspector 3 CapewideEnterprises,LLC �,-•, Company Name �F••... G�``��� 153 Commercial Street ��'"111Z usP,V%N Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DE approved system inspector pursuant to Section 16.340 of Title 5(310 CM 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3-8-14 �pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gl)d or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ***"This report only describes Conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5im 3113 Title�50"fficjal Form:Subarraoe Sewage ieposal yatdn•PaBe 1 or 17 - r Mar 0914 07:59p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Hickory Hill Circle Property Address Mary Connor Owner Owner's Name information Is required for every osterville MA 02655 3-8-14 page. city/Town slate Zip Code Date of Inspedion B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) 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: B) System Conditionally Passes: ❑ One or more system components as'described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes" "no"or"not determined" (Y, N, ND)for the following statements. If'not determined,"please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of } Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): [Sins 3113 rifle 5 OlM W hspet ian Form_SubsWaoe Sewage Die MI System-Pap 2 of 17 Mar 09 14 07:59p p.3 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Hickory Hill Circle Property Address Mary Connor Owner Owner's Name M aired for every on Is required Osterville MA 02655 3-&14 page. City/Town state Zip Code Date of Inspedion B. Certification (cunt.) ❑ Pump Chamber pumpsialarms not operational. System will pass with Board of Health approval if pumps/aiarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass Inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by 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. 1. System w7i 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 RSinE 3M3 Title 5 Ofiiciai inspectlon rorrrr SUsurtace Sewage OlWosel System•Page 3 of 17 Mar 0914 07:59p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Hickory Hill Circle Property Address Mary Connor Owner Owner's Name information is required for every Osterville MA 02655• 3-6-14 page. CilylTown State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Heafth (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 Beet 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. 3. Other: D) System Failure Criteria Applicable to Ail Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool a ® 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 a is less than 6" below invert or available volume is less than day flow 7-- Luns•3n a Title 5 0fk1W Inspechm Fan:SubsufaCe Sewage MgpoW System Pa p Mar 09 14 08:00p p.5 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Hickory Hill Circle Property Address Mary Connor - Owner. Owners game information isrequir Osterviile MA 02655 348-14 9e. for every City/Town State Zip Code Date of inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Cl ® 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. j ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, . provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fai . I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes°or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the 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 ll of a public water supply well If you have answered'yes'to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shalt upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department t5ins-M3 . Tina 5 OffWal hiepection Form:Subwdacs Sewsp Disposal System.Pape 5 of V Mar 09 14 08:00p p,g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Hickory Hill Circle Property Address Mani Connor Owner Owner's Name information is Ostervilie MA 02655 3$14 required for every _ Page. City/Town state Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any`of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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 NIA) ❑ Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ER ❑ 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 Sall Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. El ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System I nfo rmatio n Residential Flow Conditions: Number of bedrooms(design}: NA Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Mini-3A3 Title 5 Official Wgxicdon Forth:Subsurface Sewage Disposal System•Pape 6 of 17 f Mar 09 14 08:00p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Hickory Hill Circle Property Address Mary Connor Owner Owner's Name Information is Osterville MA 02655 3-8-14 required for every page. Citylrwm State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal.tank and pit. Number of current residents: 2 Does residence have a garbage grinder'? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No 2012-42,000Gais Water meter readings,if available(last 2 years usage(gpd)): 2013-28,000 Gal's Detail: i Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Cornmercialllndustriail Flow Conditions; Type of Establishment Design flow(based on 310 CMR 15.203): ' Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 45I"Is W13 TiOs 5 Offl"Inspecllon Foror$~ace Serepe Disposal System-Pop 7 of 17 Mar 09 14 08:01 p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Hickory Hill Circle Property Address Mary Connor Owner Owner's Name Information is required for every Osteryille MA 02655 3-8-14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped. gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,dh9gholizifts, 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): 15ins;•3113 Tie 5 Offlaal hspWm formr SubsuAeoe Sewage O*=W System•Page 8 or 17 Mar 09 14 08:01 p p.g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Hickory Hill Circle Property Address Mary Connor Owner Owner's Name information is required for every Osterville MA 02655 3-8-14 page. Citylrown state Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below feet grade: 1 g Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: few Comments(on condition of joints, venting,evidence of leakage,etc.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): 811 Depot below grade: 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. Precast �n Sludge depth: IRS•3113 Tito 5 Official kispectim Form:Stheinface Sewage Disposal System-Page 9 of 17 Mar091408:01p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonm-Not for Voluntary Assessments 75 Hickory Hill Circle Property Address Mary Connor Owner Owner's Name information required for every Osterville MA 02655 3-8-14 page. City/Town State Zip Code Date of Inspedion D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 29" 0. Scum thickness Distance from top of scum to top of outlet tee or baffle 12e . 18" Distance from bottom of scum to bottom of outlet tee or baffle Asbuilt-Tape How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to'outlet invert, evidence of leakage, etc.): Tank at working level.Tank and covers at 80 below grade. In and outlet baffles. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade; feet Material of construction: ❑concrete' ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Sns;3H 3 Title 5 OffWat Impedbi Fom[Subs aface Sewage Disposal System•Page 10 of 17 Mar 0814 08:02p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonn -Not for Voluntary Assessments 75 Hickory Hill Circle Property Address Mary Connor Owner Owner's Name information is Osterville MA 02655' 3-8-14 requinepage. d for every Cityrrown state. Tip Code Date of Inspection D. System Information (cunt.) Comments ton pumping recommendations,inlet and outlet bee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day . Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.):. "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins'•3113 Title 5 00bal Inspection Fan Subsurface Sewege Dispwal System•Page 11 of 17 S Mar 0914 08:02p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Hickory Hill Circle Property Address _Mary Connor Owner. Owner's Name information is Osterville MA 02655 3-8-14 required for every page cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Distribution Box (if present must be opened)(locate on site plan): 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.): Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No' Alarms in working order. ❑ Yes ❑ No' Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): I If pumps or alarms are not in working order, system is a conditional pass, Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: LMM 3113 We 5 Orfidel kmpedmn Form:a6arfac:e Sewage Diepoear System-Pepe 12 of 17 S Mar 0014 08:02p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Hickory Hill Circle _ Propedy Address Mary Connor Owner Owner's Name information is Osterville MA 02655 3-8-14 required for every paw Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number. • ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovativelaltemative system TYpetname of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching is one 1000 Gal.precast pit Pit and cover at 15"below grade. 11water in pit wlstain line at 2'. No sign of over loading or solid carry over. No higher stain line. 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 t5ire%3r13 Title 5 Modal tnspec&w Form:Subsurfam SeYAW Disposal System-Pape 13 of 17 i Mar 0914 08:03p p.14 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Hickory Hill Circle Property Address Mary Connor Owner owner's Flame information is Osterville MA 02655 3-8-14 required for every State Zip Code Date of Inspection page. cityrrown D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i Privy(locate on site plan): Materials of construc#ion: Dimensions Depth of solid Comments(note condition of soil, signs of hydraulic failure, level of ponding,,condition of vegetation, etc.): s • t5ini-3113 7119 5 Official Inspection Form:Subsurface sewep Disposal System•Page 14 of 17 i Mar 0914 08:03p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Hickory Hill Circle Property Address Mary Connor Owner Owner's Name information is Ostenrille MA 02655 3-8-14 required for every page. City/Town State Tip Code mate of inspection D. System Information (cunt.) 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 C4IA6:E 14 R EAP, cK 18 Al />1 -3 = 3 fol r � �3 t5ins 3A3 Title 5 Model Mepection Fo m:SUmOace Sewage Disposal System-Pape 15 or 17 Mar 0914 08:03p p.16 Commonwealth of Massachusetts Title 5 Offidial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Hickory Hill Circle Property Address Mary Connor Owner Owner's Name information is Osterville MA 02655 3-8-14 required for every page. Clty/Town state Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N� Estimated depth tolWi h round water. 1 te e 9 9 at 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: Lot next house over. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed'USGS database-explain: You must describe how you established the high ground water elevation: T.H. 1984 next door house. No G.W.at 13'. Bottom of pit at 7'below grade. Bottom of pit at 6 above T H Depth Before filing this inspection Report, please see Report Completeness Checklist on next page. Page 18 or 17 t9ins•3h3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System• s i a Mar 9914 08:04p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Hickory Hill Circle Property Address Mary Connor Owner Owner's Flame information is Osterville MA 02655 348-14 required for every Zip Code Date of Inspection page Cityrrown State E. Report Completeness Checklist ® Inspection Summary: A, B, C, D. or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System information-Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i 7 t5ins r 3M 3 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Pepe 17 of 17 - i Septic Inspection Information Data�Entry Date 12/8/1997 5eptr�c Ind ctt =Assessors Ma ;;; .,��, p% 234 Pareel:q 031 , of A Busyness: Numb r Cranberry Lane .v� ., 31 Address.; ,'VMlM Centerville Inspect James Sears 6/20/1997 SstemStatus NFE ommet:; QUESTIONABLE WATER LEVEL. r w 'Perm�t � � �r�Reparr�tlate, � � ` trf�atron Dated Eng/Installer „., Repare�Deadl%re;Date .. Septic Inspection Information ...fir:; > >? ""Ic( >..; ::. 10/23/2003 ..:.::.: ::.::::: .::.:::::. . 1604 WWI. 2 75 < . <W Osterville Joseph Macomber Jr. '` ` ssre `za 9/27l2003 NFE i irsiEii :'. Board.of health will have to decide if the present septic system is large enough for a five bedroom house > t#> 200 >`> ejii )€lhE4 �r . Septic Inspection Information Data�Entry Date 10/23/20031 1604 Asq lessors Ma ,,, p 120 Parcel 070 LW 0 �13usmess (km ber �,�,� 175 LAtldress.:, lHickory Hill Circle 10sterville rnspecto Joseph Macomber Jr. ulzsr.;wxza mains ect date g/27/2003 Sys err►Status NFE p,r„�,r .✓jai .�.�,.,s.... �Gommen Board of health will have to decide if the present septic system is large enough for a five bedroom house Per�mt�# 200 Repair Notificataoate � � �Engllnstaller �Repm air^D� eadhne Dater i Check nfe 2/1/2005 Pass)- number Address, Village' inspect_dat NFE 31 Cranberry Lane Centerville 6/20/1997 �° NFE 75 Hickory Hill Circle Osterville 9/27/2003 NFE 11 Nyes Point Way Centerville 10/14/2003 Page 1 Fuic....*�r&----_ THE cOwmomvvsALrH OF wAssAo*ussrTs ' BOARD �� � /T��� i~�C�/u�L� -����r�v��n=-----C)�-�-- � / ^^^~'/ v -------''-----. ---------'-- �_°� � �� �������v�ww�� ����m� u�x��� ���������,�o� Vrrmit Application ~ is hereby made for Permit to Construct ( '��~^ Repair ( ) an Individual 6^ Disposal .S stern _ �� � �����--- .._��-' ----_------- � �*�� ^ --»-- '----�p'---~x�=-- ----'-------___'-__�___________________________ Address -'---�r-�- '-�-�� -----------'------- --------''-'-------'- �--------------'------------ . AddressTvneofB � ~ Size Lot............................Sq. fee Dwelling.9YJn. of 8e6rono/e---...-.;....��_-_---' Attic /K Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) -- Cafeteria ( ) P4 Other fixtures Seepage Pit No.- D i am eter 6t4 bepth below inl ........ Total leaching area.._15?._�-d'­"X�q. ft. Z Other Distribution vvz ( ) Dosing tank \ � '- Percolation Test ]lcoulty Performed by.......................................................................... Date....................................... Test P6 No. l................minutes per inch I)coth of Test Pit-----'- Depth to ground water........................ �14 Test Pit No. 2................ cd ............... ..................................................................................................................... ^' Description of x....................................................................................... ------- .................... -------`--- `--`---`-------```----`---'--------`-`----- | Z --'--'------'--'.--'''-----'--'---'--------'--------'----'-----''------------ U Nature of Repairs or Alterations--Answer when ---.--.-----------.--_---------.-_-- � __-_'.-''''--_---_--_-.-'----_--__----'----------------_.---_---------.____- Agrccmrur: The undersigned agrees to install the uforedescribed Individual Sewage Disposal System inaccordance with the provisions of Article XIof the State Sanitary Code—The undersigned further agrees not to place the system in � operation until a Certificate of Compliance issued S ....... ................................ � Application Approved Dv- ------- —'-.--Application Disapproved Date forthe following reasons:.................................................. ............................................................. ......................................................................................................... No........9/1 .., Fes$..:._ :.......:....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE.A 'TH OF Applirazillit for Big asai lVarkg Tui'strurtiou Permit Application is hereby made for a Permit to Construct ( P010"oo'r Repair O an Individual Sewage Disposal System t t, c tt dasof Qwnet Address � .,..• r.. �,�. ,................................... ............................. ............Address,......_..............................._... Ins U Type of Buz Size Lot..................... ......Sq. feet ., Dwelling 47No. of "Bedrooms................ ..................Expansion Attic ( Garbage Grinder ( ) Other—Type T e of Building --.__- No. of persons........................_._ Showers — Cafeteria (� YP g P ( ) ( ) P4 Other fixtures . W Design Flow.............................. ._._ allons per person per day. Total daily flow____..... .+ ............. 0� Septic Tank—Liquid capacity #1 gallons Length................ Width................ Diameter................ Depth.................. Disposal Trench—No..................... Width..... :.. . Total Length........ Total leaching area....� ....sq. ft. Seepage Pit No...... Diameter�........_... � �. Depth below inlet-------- Total leaching area..: t7. : ft. Z Other Distribution box'( ) Dosing tank'( ) aPercolation Test Results Performed b.Y.......................................................................... Date:--................................. . a Test Pit No. f...:...........minutes per inch .Depth of Test`Pit.-.............____. Depth to ground water........................ tZ Test Pit No. 2................minutes per inch Depth of Test. Pit.................... Depth to ground, water____-___---_.-_--------. O Description of Soil-------- ?t . ........... ....I x U ........................-.......................................:........................................:•----•••-...••-•-•-••------•---•----------•---••-•••••......---•--•-----.....---••-. ••-----••••---------------------•-----•-••-••........................•... --------------------•------------------------------------------------------------------------------------------------•-------- 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health Signed s ........... - } f Date -� Application Approved By..__. a,�.. r �s G°� - .V Date �- Application Disapproved for the following reasons:......................... ------------.......----------------......_.....------------•--••-._........... •----•-•--•----------------............................................................... -•--•••--••...-----•------•--•---•-•--••-------------•-----------•-•-••---•-•---•-------••••................. Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH,-,,— ........ fit It-Entifiratr of Tomp1iaurr THI TO CERTI Y hat-the Individual Sewage -'s osal System constructed ( ) or Repaired ( ) by:...r :.: `. t -.,' ....... � ---- ---------•--.....---.......----•-.....---................ a Si zlt --------------------------•--••••••-•......•••••.....--•---••---••---- has been installed in accordance with th" )rovisions of Article XI of Tile State Sanitary Code s des ribed in the application for Disposal Works Construction Permit No------------------------- _ ___ __ dated----- __ _ `....._........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................. Inspector........................................................... ----...........,........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF .HEAL., y .. r�` ........ O F....... ' . No......��/.. ;. FEE- . Permission 's ereby grantedfdZ .---- to Con str or Repay t( z`R t nd7�! ? u a1 po Sei. :.. ... ...... t - . . ................. at No.. ... e. .... .. ,.. Street i� v- as shown on the application for Disposal., orks Construction. P. ff o.. . .. r.. " ated._... .... Board of calth DATE................................................................................... FORM 1255 J-1083S & WARREN, INC.. PUBLISHERS .. MUHAN LNU 1 Nt tLX 1 Nl, 1 Nl; V• b 1 V f. , FORM 1.1 - SOIL EVALUATOR FORM j page 1 of 3 I Date: No, Comm nwealth of Massachusetts Massachusetts s /i~ ► ..site Sew a Das osal Soil Suitabilr As ssf en or On �.. Date:` e .. :.:..... . �... .. � , Performed By' .�cZ C?./....... .. ... '.. .... ............... Witnessed By: .., L;6ci:ion Amu=a L 17-/- s,�v�dr� 1 / e g, / Ile A I PC �ewcoTnstruction I Repair a , Office: Review -Published Soil Survey Available; No Yes S�l�C3 Soil Iola Unit ' .......... Published � .:.... ....... pub ieation Scale �r P YearP ........... :......... ..:........ ..... ......... ........,. Imitations Drainage Class .. Soil �• .......................:.......... Surficial Geologic Report Available: No ❑ Yes P blieatlon Scale' .. ....:.,;;:A. a . Published ............... Year .......................................... ........... .. a Unlit Geologic Material (Map ) ................ ........... Landform Flood Insurance Rate Map: es Above 500 year flood boundary No ❑ _ Within 500 year flood boundary No ❑Yes ❑ Within 100 year flood boundary No ;yes .❑ Wetland Area: ... National Wetland Inventory Map (map u It), Wetlands Conservancy Program Map (n1 P unit) Month .... . .... Current Water Resource Conditions (U SGS) •Above Normal []Normal Belc�•i.Normal El Range . ___:.. .. .. Other References Reviewed: r DFF p pPROM FILM•12107195 MORAN- ENGINEERING-INC 5094326537 P. 02 i F OMI 11' - S011,->E='VALUA.TOR NORM Page 2of3 Location Address or Lot No. /,�� �� �� '�'�.�,��/�'V�c�rnf�''`•�9�� On-site Re—View I . Deep Hole Number ..1. � Date:. /..c''r �l Time:, i�7 Weather Location (identify on site plan) �� ed Surface Stones . Land Use : < r»`/ Slope ( /o) . -.�a`T ..... Vegetation :. ..A/1,07 y li.Si . Landform Position on landscape sketch on the back) Distances from: feet } Open Water Body>,Ya41 feet i Drainage way .. Possible Wet Area T l�O feet Property tine >/a.. .: feet Drinking Water Well ,.--.• feet Other . DEEP QgSERVATION HOLE _OG� - i Other h from Soil Horizon Soil Texture Soil Color Soil 1 Surface(inches} (USDA) 1 (MunseiU Mtottling. (Structure,StoneS�G avleljrs' Consistency, °� pept 7 0,0171 Syr I OepthtoBadrock: Parent Material(geologic) -� i _.. • Weeping Fro.rti Pit Face: r in the Hole Depth tc Groundwe er: Standing water - - Estimated Seasonal High Ground Water: - . DEP APFftOYBD F0RN1 12161(93 MORAN ENGINEERING INC 5084326537 P. 04 i FORM.ZI - SOIL LVALUATOR FORM i Page 3 of 3 k Location Address or Lot No. .01 Determination Por Seasonal Higji Water Fable Method Used: ❑ Depth observed standipg_in observation haled%�.. ❑ Depth weeping from side of observation hole �.e.ipahe-s ❑ Depth to soil m0ttles/1/10 .e ,iriuK , ❑ Ground water adjustm nt Mw.e_ 4 Index Well Number ................•. Reading Date ..............:.. Index well level ..,..:......... Adjustment factor.................. Adjusted ground water level ...........................,....,,.............7.. Dept of Natural) Occurrin Pervious Material Does at least four feet of ;naturally occurring,pervious material exist in all areas observed throughout the area proposed for.the soil absorption system? If not, what-is the depth of�naturally, occurring pervious material? Y Certification I certify that on f /G (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15,017. • Signature�i�� MORAN ENGINEERING - INC 508432E.537. P. 05 i FORM .12 - PERCOLATION TEST Location Address or Lot No.21.1 r•:r�cir �" �.�.°�� ram, ,��, . COMMONWEALTH OF MASSACHUSETTS' Massachusetts Pereola ion Test* Date: ��'�c?5�� Time:, Observation Hole # Depth of Perc Start Pre-soak End Pre-soak �S , Time at 4r /D " 1 . Time at ' Time at Time OW) Rate Min./Inchr� . * Minimum of 1 percolation test)must be performed in both the primary area AND reserve area. Site Passed Site Failed Performed By: Witnessed By: Comments: DEP APPROVED romt.12/07/95 MORAW ENGINEERING INC' S084326537 P. 03 T i - I . r