Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0105 HICKORY HILL CIRCLE - Health
105 HICKORY HILL CIR., OSTERVILLE A v i 0 1406... THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH (-. . -R- ............................ ........... 0 U)11�.........0 F.......R.A. .1. Appliration for Disposal Morks Tonsuvrtivn ramit Application is hereby made for a Permit to Construct (!/f�or Repair an Individual Sewage Disposal System at: ............................. ...................................... Loc ;,"z ,�;;w- or Lot No. 10 S ...................... X.. 6........................................... Owner .............. Address ..........................................F. .......I .............. ............................................................................... .............. 1.4 Installer Address 1.!.;i Type of Building Size Lot....... I.Sq. feet U Dwelling—No. of Bedrooms..................4......._..........Expansion Attic Garbage Grinder 1:14 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria 111 Other fixtures -ell ,.;................................................................................................................... Design Flow............. ..gallons per person per day. Total daily flow........................ Septic Tank—Liquid'...capacity.j.,)CCgallons Length................ Width................ Diameter......_......... Depth.....__......... Disposal Trench—No..................... Width........t.......... Total Length.................... Total leaching area...... .......sq. Seepage Pit N I o....... ..v iameter..........1F...... Depth below inlet................ Total leaching area..Z��.sq. ft. z Other Distribution box ( Dosing tank ( ) Percolation Test Results Performed 1)?��. ex't-d't.d......... h4t.PS...087 Date......... =_72-.a3........ 1.4 1.4 Test Pit No. I....._71—. ..minutes per inch Depth of Test Pit.........1.2, Depth to ground water.......`.......:...... Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................ ...................*-------**......*'**"*'**...............".......*--------*................. 0 Description of Soil..... ......... ------------------- ----------- ............. ................................................ ......................................................................................................................................................................................................... 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"LITIME 5 of the State Sanitary Code— undersigned further agrees not to place the system in operation until a Certificate of Compliance b he,oboa5o of health n ............a. ........................................ ........... ....... ......... D Application Approved By......'... .. .. .. .. . ............. �tie .............................................. /.. .......... ... .................. ate Application Disapprov or e follouring reasons:..........................................................................................................--- ................................... ........ ...................................................................................................................................................... Date PermitNo.................................................... Issued.......................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �...�1.L1�.�.1.........OF...... 7N. .......................................... ( Appl ration for Disposal Works Tonn#rurtion rprmit Application is hereby made for a Permit to Construct ( t, or Repair ( ) an Individual Sewage Disposal System at: ( rr? t ................___...._...... ...� .�..�°��t I-__.---•'•�=L==�•-�c,--1 '��r---c �::�-=.�......_......_��.__.... Location.Add ss + or Lot•No. ....................____... ..... fi...--: ......._•---...4. ..:f+'..'..'.?:r.....................................................•-............................. ,Owner � Address W -...... .......L C 1'- ....................C_ 4� ...............•......---.........:........--••--•-•••-- •-�................................... ...................... Installer Addresa Type of Building Size Lot....:`..>;� ! . ..Sq. feet U Dwelling—No. of Bedrooms.................... _..................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons........................ Showers G4 YP g ----•-•-•---....---••--••-•- P ---• ( ) — Cafeteria ( ) a' Other fixtures r" W Design Flow................... ...........—gallons per person per day. Total daily flow...................... .....gallons. WSeptic Tank—Liquid capacity.1` llons Length................ Width................ Diameter................ Depth................ xDisposal Trench—No................:.... Width.................... Total Length.................... Total leaching area...................sq. ft. 3 Seepage Pit No........Z--..... Diameter...........& ..... Depth below inlet..... ........... Total leaching area....,e�( .sq. ft. Z Other Distribution box ( 1411 Dosing tank ( ) _ # ( ` r _ `" Percolation Test Results Performed by: > : . ti.� :.!:.1��.'.�.4 ......-.t.....: :':E_`? Ezi. te........¢=.1......�� • a 7 Test Pit No. 1......7�.minutes per inch Depth of Test Pit............._2— Depth to ground water.................. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ pG ..•-••-•••••............................••-••---.....•••....__..--___--_-------•--•---•_-•------ •... ••-•.... •........ •---------------------- •...... •-- 0 Description of Soil........................................................................................................................................................................ ... .. .V ------------------- 17/_�. r ...........:. .f .!:t.t .................................................. 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—T undersigned further agrees not to place the system in operation until a Certificate of Compliance h b he oar-d of&lith,,,ed . t4t!! -. ........................ ........ _.... - a Application Approved By....... . ....-•-•--•--•.........................•-•----•-•-------- ..-- = a�---• S Date Application Disapproved r t following reasons............................................................................................................--- .................................... .... ......._-___._...•-•••-•----•--__........____...••-•--•......-•-•--.......•--•-----•......-•---••-•-•-..................••--_.. ..........._ Date PermitNo.................................•........-------_.. Issued....................................................... Date F , THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......OF........ -!�.'. f�4f. �!..!'..1. �` ........................... Gr#if irtt#r of Tonmpl aurr . THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( �or Repaired ( ) by...............•---•• i /?v .......... - -�c `=-�=©---•---•-- --•--------..._.........._....•--•-••-----•--......_._..............---••••-....._._........_ / - flier at.............•.%.-e-�....-.......Z�g.�._......... 2i�._`"......... f ._.._.._.. has been installed in accordance with the provi ons of TI �F ` o The State Sanitary nitary�' a esc ibed in the application for Disposal Works Construction Permit No.._- 7... ............. ----- THE ISSU NCE OF THIS CERTIFICATE SHALL NOT BE CONS AS A GUARANTEE THAT THE SYSTEM��L FU ION SATISFACTORY. DATE.........22 .... ... ................................................ Inspector ... •----•....----•------......--•-----•-..........._•-------.................... THE COMMONWEALTH OF MASSACHUSETTS — - BOARD OF HEALTH No . ...........OF........1 �' //h� .: ........................ ............. Disposal Works Tonntrurtion rrrmft Permission hereby grant � .t✓L 17. LLc) - ... .....--.•----.......... to Constru or Re r Ind vi age Disposal System atNo. -.-.. ... .. ..... ""...- --•-- -------•----...-•-•...............•-......_.......lxz - Street as shown on the application for isp Works Construction Permit NO. .: ated. ---.•. ........................... ....................•-•-•. .........................................................._ DATE.......... /L j el—� oard of Health ... ................................ FORM C-1255 CITY& TOWN FORMS, INC. 369-9708 . ' D G 1�� <7 L�.T A • • LE FAM 1 Lam( 5EYt1G TAy►�Cy-,_A4a .y�SPoSAI: PST � V;i✓ 2'(�22�_�-�"�r ._ . . . � ` AoIAM .. . ,. AX i 50Tr0A^ A ZMA s t j oo. • I '. . .. A . . . . . . : :' GO .�.�•v: l dam: f Y I ' ... .. ToTAv t�l`s%G�-L PEY.co LA-r(C)W P-ATL' 1"m 2 Aw o(Z UA6, ...-: ; ------. '� ' !- , - •..'/l e, 3o AN PL S BAXT-R' Tlo:'2 �B r 5 it.. .. � .. .... \ •- Y itiv �w c� lop FWD �O INV y/. . C. 1000 WtTO �lN . CTU N 6 C Va-T 1 F i E D vLo-r Pt_.A tza i t.c�G,d,T106.1 1 G6�ICTIFY T"AT ►-lEQo►J Y T VSg' S�lowu __ E. " CAMgL- ,5 wtTM -r"c6 rrmewM•t� IQ'. AWI> St�T`HAC�C R J��•MEa►.tTrj O T61E l 8:1.. I law tbwal OF 1N`ITQi Ak�1D 1 isL. �J�.. . V�.I... ' �G i I 1Aus, l� WITNI w 1-1 _ t� P AIIJ. ( }....; 7_.1�- ISTw& TLEc� LA6.1D irrL)Qv�ov TuIS FLAW fir � 140T BASED OLI AU 16-KTeame1T OST V6t.Lim'. �MA••55• SuevC/ �, T06 OFFSQT;, •5W0.ULD uoT 156 USe1> ! ApPLIG A WT ARCS V ►F` t,�,�_To LIUE:;, No. © Fee—. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes - Application for Di5po5aY 6pftem Cun.5truction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1135 ��e(y �1 UQ t Owner's Name,Address,and Tel.I�jo o Assessor's Map/Parcel ,ar '7 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 9,enouP bc)� MT) ('98y�bk!eoc-\ 1-- 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 Certificate of Compliance has been issued by this Board of Health. Signe Date i Application Approved by Date , Application Disapproved by: Date for the following reasons Permit No. �) Date Issued �- No;. U I y Fee a v THE COMMONWEALTH OIF MASSACHUSETTS Entered in computer: el_< T PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes yam`' 0[ppYication for Migpogal �&pgtpm Con5tructiou Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. 105 1�Q�`e� t���` ����e Owner'Name,Address,and Tel. o.� C. O��ety �t -CAS 9 Assessor's Map/Parcel `a 7 g Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ass Type of Building: Dwelling No.of Bedrooms Lot Size _ sq.ft. Garbage Grinder (. ) Other Type of Building No.of Persons Showers( ) -Cafdteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd i Plan Date Number of sheets ;Zeision Date Title Size of Septic Tank Type of S.A.S. Description of Soil f ) n Nature of Repairs or Alterations(Answer when applicable) `�ej to aef Date last inspected: Agreement: . y _ The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health _ Signed �'--- Date ___--- �V--Application Approved-by--- ,<:Date l Application Disapproved by: 3 Date , for the following reasons Permit No. O { a Date Issued THE COMMONWEALTH OF MASSACHUSETTS d BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-siteLSewa`ge isposal System Constructed ( ) Repaired (V ) Upgraded ( ) ~' Abandoned( erg)by / //lJ�/ 9S ; 5, All/ at has been constructed in accordance with the provisions of Title 5 and the for ispo ai System Construction Permit No. '�C3/3 � }a1-4 dated Installer/j��j ��Z/1`j(�0�� �,l�S �t�f�`""�- Designer _ #bedrooms Approved design flow gpd The issuance of this permit shall not b'construed as a guarantee that the system ill funct'io -asn es'gne . Date "7 Inspector � r ---------------------------------------------- No.-.d / 0.___.. - - Fee /.Q THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Migpogat �&pgtem CoHgtructton Permit Permission is hereby granted too�Construct ( ) Repair ( �. Upgrade ( ) Abandon ( ) System located at�� 1`7/C�l/✓�'7 � l�I /lT Os�/�`/�-�//�� 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 m, st be co pleted within three years of the date of his pe Date �� � 3 Approved b�, oJ / c SEWERAGE PERMIT N0. � in LOCATION: vl VILLAGE: D�Sf2��y�/�� I i 2.1 04- 1 eJ INSTALLER'S NAME: u ADDRESS: BUILDER'S NAME & ADDRESS: I DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED:. . `yfagi' �* J ' � r f Commonvyealth of Massachusetts R Title Official Inspection Form 1 Subsurface i ewage Disposal System Form -Not for Voluntary Assessments >v M 105 HICKORY HILL CIRCLE Property Add Owner KATHERINEICASTIGNETTI information is Owner's Name required for every page. OSTERVILLE MA 02655 MARCH 14, 2013 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: A. General Information When filling out forms on the computer, 1, I nSpeCto I: use only the (/ 1/ tab key to MARK L WHITE move your Name of In pector cursor-do not use the return NEIGHB RHOOD WASTE WATER key. Company lame San C) 350 RT Z18 Company Address WEST YARMOUTH MA r` ' `n City/Town ' Statep2673 **, tenon .Zip,'Code. +,"•� 508-775-2820 S113381 Telephone dumber 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 w4s performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR.15.000).The system: 'L1"OF IygsOiyw FX ❑ yak ........, Passes Conditionally Passes FaiW MARK yN ❑ =0: WHITE m? Needs Further Evaluation by the Local Approving Authority No.513381 RTIP\ MARCH 14, 2013 j�mtNSP,E�`o``��� nspector's(Signature Date. The syst m inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the.DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. i ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Officia speck o $�Ulege Disposal System•Page 1 of 21 CommonvIrealth of Massachusetts Title Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 105 HICKORY HILL CIRCLE. Property Add Owner KATHERINE(CASTIGNETTI information is Owner's Name required for every page. OSTERVILLIr MA 02655 MARCH 14, 2013 City/Town IState Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System asses: x❑ I'1have 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 evaluate are indicated below. Comments: B) System conditionally Passes: O �ne or more system components as described in the"Conditional Pass" section need to be r' placed or repaired. The system, upon completion of the replacement or repair, as approvec by the Board of Health, will pass. Check th a box for"yes", "no or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The Sept c 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 approve by the Board of Health. ' A metall 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. El � N ❑ ND (Explain below): f { t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System'•Page 2 of 21 i Commonwealth of Massachusetts jitle � Official Inspection Form Subsurface ewage Disposal System Form-Not for Voluntary Assessments 105 HICKO Y HILL CIRCLE Property Add Owner KATHERINE CASTIGNETTI information is Owner's Name ' required for every page. OSTERVILLIi MA 02655 MARCH 14, 2013 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distributi n box. System will pass inspection if(with approval of Board of Health): broken pipe(s) are replaced . ❑ Y ❑ N ❑ _ND (Explain below): ff 4 obstruction is removed ElY El N. ❑ ND (Explain below): f distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): 4 . 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): 0 broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): f ❑1 obstruction is removed ❑ Y ❑ N ❑ ND (Explain below). i E I i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 HICKORY HILL CIRCLE Property Add Owner KATHERINE CASTIGNETTI information is Owner's Name l required for OSTERVILLE� - MA 02655 every page. MARCH 14, 2013 City/Town State Zip Code Date of Inspection I l C urther 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 B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) i determines that the system is functioning in a manner that protects.the public h�alth, safety and environment: i The system has a septic tank and soil absorption system SAS and the SAS is Y p p Y. (SAS) 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. 4 The system has a septic tank and SAS and.the SAS is within 50 feet of a private water supply well. ❑ 4he system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or - more from a private water supply well". Method used to determine distance: **This s stem 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 tale analysis must be attached to this form. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 21 IL' 1 Commonvrealth of Massachusetts Title Official Inspection Form ^' o Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 105 HICKORY HILL CIRCLE Property Add Owner KATHERINE!CASTIGNETTI information is Owner's Name i required for l every page. OSTERVILLE MA 02655 MARCH 14, 2013 City/Town State Zip Code Date of Inspection 3. Other I D) System fOailure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes }No ElBackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ `0 Discharge or ponding of effluent to the surface of the ground or surface I 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 ❑ z Liquid depth in cesspool is less than 6" below invert or available volume is j less than '/z day flow B. Certification (cont.) Yes No ❑ 0 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. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑X Any portion of a cesspool or privy is within a Zone 1 of a public well. 0 i 0 Any portion of a cesspool or privy is within 50 feet of a private water supply {I well. I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 21 fi l . Commonwealth of Massachusetts jitle 5 Official Inspection Form 5. Subsurface ewage Disposal System Form,-Not for Voluntary Assessments * 105 HICKORY HILL CIRCLE Property Add Owner KATHERINEICASTIGNETTI information is Owner's Name required for OSTERVILL i - every page. MA 02655 MARCH 14, 2013 City/Town I State Zip Code Date of Inspection ❑ 0 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. ❑ ❑x 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 f ow 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 ques ions in Section-D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply El ❑ the system is within 200 feet of a tributary to.a surface drinking water supply ❑ El the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone Il 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. C. Checl'Iist Check if the following have been done. You must indicate"yes'or"no"as to each of the following] Yes N�o. ❑ LX Pumping information was provided by the owner, occupant, or Board of Health ❑ l Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 21 i Commonwealth of Massachusetts jitle 5 Official Inspection Form Subsurface ewage Disposal System Form -Not for Voluntary Assessments 105 HICKORY HILL CIRCLE Property Add j Owner KATHERINEIICASTIGNETTI - information is Owner's Name required for every page. OSTERVILL MA 02655 MARCH 14, 2013 City/Town State Zip Code Date of Inspection El x Have large volumes of water been introduced to the system recently or as part of this inspection? I 7Were as built plans of the system obtained and examined? (If they were not 0 0 ! available note as N/A)N/A 0 4 Was the facility or dwelling inspected for signs of sewage back up? i ❑X Q Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of . scum? Was the facility owner(and occupants if different from owner) provided with I- information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑x Existing information. For example, a plan at the Board of Health. 0 �( ' Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance.is unacceptable) [310 CMR 15.302(5)] { D. System Information Residential Flow Conditions: Number of bedrooms 4(design): Number of bedrooms (actual):3 DESIGN I flow based on 310 { CMR 440 15.203 (for example: 110 gpd x# of bedrooms): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 21 Commonwealth of Massachusetts To Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 HICKORY HILL CIRCLE Property Add Owner KATHERINEICASTIGNETTI information is Owner's Name required for OSTERVILL� MA 02655 MARCH 14 every page. , 2013 Cityrrown State Zip Code Date of Inspection D. Syste In Information Descripti' n: Number of current residents i: I. Does residence have a garbage grinder? ❑x Yes El No Is laundry on a separate sewage system? [if yes separate inspection Yes ❑ required] No Laundry system inspected? ❑ Yes ❑ No Seasona use? Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 21 I Commonwealth of Massachusetts Title 5 Official Inspection Form - �' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 HICKORY HILL CIRCLE Property Add Owner KATH ERI N E:CASTIGN ETTI information is Owner's Name required for OSTERVILLE MA 02655 MAR CH 14 2013 � eve a e. , fY P 9 Cityrrown i State ZipCode f Date Inspection Water meter readings, if available (last 2 years usage (gpd)): 2011-147,000 2012-95,000 i Sump pump? ❑x Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: I - 1 1 Design flow(based on 310 CMR 15.203): Gallons per day(gpd) I Basis of design flow(seats/persons/sq.ft., etc.): , Grease trap present? - - El Yes El No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No Water meter readings, if available: D. System Information (cont.) i Last date,of occupancy/use: Date Other(describe below): i t l i . t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 21 i . 1 i 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments — � l 105 HICKORY HILL CIRCLE Property Add Owner KATHERI NE!CASTIGN ETTI information is Owner's Name reuired for every page. OSTERVILLE MA 02655 MARCH 14, 2013 CitylTown State Zip Code Date of Inspection General Information i I t , I Pumping Records: I i i I Source of information i I . Was system pumped as part of the inspection? ❑ Yes ❑x No i If yes, volume pumped: gallons I How was!quantity pumped determined? I t Reason for pumping: 1 Type of System: FX Septic tank, distribution box, soil absorption system El Single cesspool i ❑ 1 Overflow cesspool i . I ❑ Privy t5ins•11/10 II Title 5 Official Inspection Foam:Subsurface Sewage Disposal System•Page 10 of 21 I . i i i I i Commonwealth of Massachusetts Title Official Inspection Form ' _ o Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments 105 HICKORY HILL CIRCLE Property Add ; i Owner KATHERINE1CASTIGNETTL information is Owner's Name required for every page. OSTERVILLIf MA. 02655 MARCH 14, 2013 City/Town State Zip Code Date of Inspection ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) I ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest i inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe) D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information:9/83 Were seage odors detected when arriving at the site? El Yes ❑x No Buildingsw Sewer(locate on site plan): i Depth below,grade: 191, l Material f construction: ❑cast it n ❑x 40 PVC ❑.other (explain): - Distancelfrom private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage,.etc.)` INSPECTED MAIN LINE WITH SEWER CAMERA, LINE WAS CLEAR. i i Septic T nk(locate on site plan): Depth be{low grade 9 Material of construction: ❑x concrE to ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 21 i Commonwealth of Massachusetts TitleOfficial� i Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 105 HICKORY HILL CIRCLE Property Add Owner KATHERINE CASTIGNETTI information is Owner's Name required for every page. OSTERVILLI$ MA 02655 MARCH 14, 2013 . City/Town State Zip Code. Date of Inspection If tank is I metal, list age: years Is age coinfirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ certificate) No l Dimensions: Sludge d pth: } D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thi kness 3 Distance from top of scum to top of outlet tee or baffle Distance!from bottom of scum to bottom of outlet tee or baffle f 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 of leakage, etc.) i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 21 Common 'ealth of Massachusetts tle I jiOfficial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 HICKORY HILL CIRCLE Property Add Owner KATHERINE CASTIGNETTI information is Owner's Name i required for every page. OSTERVILLE MA 02655 MARCH 14 2013 City/Town I State Zip Code. Date of Inspection INLET&OUTLET TEE IN PLACE AND TANK IS INS GOOD SHAPE AND NOT IN NEED OF PUMPING A THIS TIME Grease Trap(locate on site plan): Depth below grade: feet Material f construction: ❑ concrIe ❑ 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 I�lst pumping: Date D. System Information (cont:) Commenits(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.):. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 21 I. Commonvyealth of Massachusetts Title v Official Inspection Form Subsurface ewage Disposal System Form -Not for Voluntary Assessments 105 HICKO Y HILL CIRCLE Property Add Owner KATHERINE CASTIGNETTI information is Owner's Name required for every page. OSTERVILL MA 02655 MARCH 14, 2013 Cityfrown State Zip Code Date of Inspection Tight or Holding Tank (tank must be pumped at time of inspection) locate on site plan):, Depth below grade: Material of construction: El concrE to ❑ metal ❑a fiberglass ❑ El otherpolyethylene (explain): Dimensidns: Capacity gallons Design F ow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order; El Yes ❑ No Date of last um in : P P 9 Date . Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? . ❑ Yes ❑ No l D. Systein Information (cont.) Distribution Box (if present must be opened) (locate.on site plan) Depth of liquid level above outlet invert AT INVERT t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 21 Commonwealth of Massachusetts _ Title Official Inspection Form Subsurface ewage Disposal System Form -Not for Voluntary Assessments *M 105 HICKO Y HILL CIRCLE Property Add Owner KATHERINE�CASTIGNETTI information is Owner's Name required for every page. OSTERVILLE MA 02655 MARCH 14, 2013 City/Town State Zip Code Date of Inspection Comments (note if box is level and distribution to outlets equal, any evidence of solids carryove , any evidence of leakage into or out of box, etc.): DISTRIBUTION BOX IS NEW Pump Chamber(locate on site plan): Pumps.ir working order: ❑ Yes ❑ No Alarms i working order: ❑ Yes ❑ No Commeni s (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Abs I rption System (SAS)(locate on site plan, excavation not required): If SAS n t located,.explain why: . t5ins-11/1 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 21 Commonvfealth of Massachusetts Title 5 Official Inspection Form Subsurface ewage Disposal System Form-Not for Voluntary Assessments ` 105 HICKORY HILL CIRCLE Property Add Owner KATHERINE CASTIGNETTI information is Owner's Name L required for every OSTERVILL - MA 02655 MARCH 14 2013 page.9 e. City/Town State Zip Code. Date of Inspection D. Syste I Information (cont.) Type: - leaching pits number: 2-6X6 PITS ❑ leaching chambers number: ❑ leaching galleries. - number: ❑ leaching trenches number, length: leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology' Commen s(note condition of soil, signs of hydraulic failure, level of pondin9 P, dam soil, condition of vegetation, etc. BOTH PITS ARE DRY t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 21 Commonwealth of Massachusetts Title 5i Official Inspection Form _ _ o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f 105 HICKORY HILL CIRCLE Property Add Owner KATHERINE CASTIGNETTI information is Owner's Name required for every page. OSTERVILLE MA 02655 MARCH 14, 2013 CitylTown State Zip Code Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number nd configuration Depth-lop of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction .Indicatiorni of groundwater inflow ❑ Yes ❑ No D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,): Privy (locate on site plan): Materials of construction: Dimensi ns Depth of IS olids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 21 Commonv ealth of Massachusetts :) Title & official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 HICKORY HILL CIRCLE Property Add Owner KATHERINE ICASTIGNETTI information is Owner's Name required for every page. OSTERVILL MA 02655_ _ MARCH 14 2013 a City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch df Sewage Disposal System: Provide a view of the.sewage disposal system, including 9 P Y 9 p Y 9 ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Loc to where public water supply enters the building. Check one of the boxes below: ❑ Band-sketch in the area below ❑x ddrawing attached separately t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 18 of 21 Commonvyealth of Massachusetts jitle ®fficia.l Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 HICKO Y HILL CIRCLE Property Add Owner KATHERINE CASTIGNETTI information is Owner's Name required for every page. OSTERVILL - MA 02655 MARCH 14 2013 a e. City/Town State Zip Code Date of Inspection D. Systein Information (cont.) Site Exam- heck Slope ❑x Surface water t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 19 of 21 i Commonwealth of Massachusetts Title 5 Official � cal Inspection Firm o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 105 HICKORY HILL CIRCLE Property Add Owner KATHERINE ICASTIGNETTI information is Owner's Name reuired for every page. OSTERVILLE MA 02655 MARCH 14, 2013 City/Town State Zip Code Date of Inspection ❑x heck cellar ❑x hallow wells Estimate) depth to high ground water: fee 2 FEET Please indicate all methods used to determine the high groundwater elevation: ❑x Obtained from system design plans on record If checked, date of design plan reviewed: 9/12/83 . 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: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 20 of 21 Common 'ealth of Massachusetts Title i Official Inspection Form �' _ o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 HICKO�Y HILL CIRCLE Property Add Owner KATHERINE�CASTIGNET-n information is Owner's Name required for every page. OSTERVILLIfMA 02655 MARCH 14, 2013 City/Town State Zip Code Date of Inspection You must describe how,you established the high ground water elevation: FROM PLANS AT B.O.H. DATED 9/12/83 Befo; a filing this Inspection Report, please see Report Completeness Checklist on next page. E. Report Completeness Checklist Inspection Summary: A,'B, C, D, or E checked 0 I�spection Summary D (System Failure Criteria Applicable to All Systems) completed 0 ystem Information—Estimated depth to high groundwater ketch of Sewage Disposal System either drawn on. page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 21 of 21 r rq i . � _ a httpa/town.Barnstable.ma.us/AssessinglHMdisplay.asp.m ppar=121a41&seq=1 3/7/2a1 -0 DATE: _ 4/19/96 PROPERTY ADDRESS: 105 Ai n_kory 'Hill 'Cj,rcl P RECEIVE® Osterville,Mass . APR ? 5 1996 02655 HEALTH DEPT. - - -- ' TOWN OF EARNSTA►,LE On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1-1500 gallon septic tank. 2. T-Distribution box. 3. 2-1000 gallon leaching pits . Based on my Ins.,*ction, I certify the following conditions: 1 . This is a ..title five septic system. ( 78 Code ) . 2. The. septic system is in proper working order at the present time . 3. No repairs are needed at this time. SIGNATURE: Name: J. P .Racomber Jr.. ------ ---------------- Company:_J. P.Macomber. & Son-,*Inc .. , Address:_-Be�c-bb-____-�_--,-- __Cente,rvi11e LMass__02.632 t. Phone:--' 548 ' I THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY ,IOSEPH P. MAC03BER & SON, INC. Tanks-Ceupoola-Leachflelds . Pumpsd & Installod Town Sewer Connectlons P.O. Box 66' Centerville, MA 02632-0066 775-3338 '775-6412 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection WUllam F.Weld Trudy Coxe GQ"Mor Argoo Paul Celluccl Dav{d BCorrn, �r,.r LL Governor is •e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 105 Hickory Hill Circle OstervilleAddreaa of Owner. 54 Broad Reach Street Date of Inspeol1on:4/19/96 (If different) # 305 North Weymouth Name of Inspeotor.Joseph P. Macomber Jr, Mass . 02191 Company Na:ne,Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 CentervUle ,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses Conditionally Passes u _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signl Date: a �T` �✓ The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner And copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: Al SYSTEM PASSES: —ice— i have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: )~One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes,po, or not determined(Y, N,or ND)'. Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is.metal, cracked, structurally unsound, shows substantial infiltration or exfrltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 021N a FAX(617)556-1049 a Telephone (617)292.5500 �� Printed on Rayekd Paper r - R SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) proportyAddroas: 105 Hickory Hill Circle Osterville ,Mass . 02655 Owner. Andria White Date of Lupeotions 4/19/96 BI SYSTEM CONDITIONALLY PASSES(continuos) Sawage backup or breakout or 4� stack water Isvel observed in the distribution boat Is die to broken or obstr sited pipa(s) or due to a broken,settlod or Nneven distribution box. The rystem will pass inspection if(with approval of the Board of Health); broken pipa(s)are replaced . obstruction is removed -. distribution boai is levelled or replaced La The system required pumping more than four times a year due to broken or obstructed pipe(s). The systam will pass inspection if(with approval of the Board of Health). broken pipes)are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTIL i O - Conditions exist which requirs further(valuation by the Board of Health in order to determine it the system is tailing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS-NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is withiir 60 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT; ` The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a rurface water supply. The system has a septic tank and&oil absorption system and is within a Zone I of a public water supply well. The system bas a septic tank and&oil absorption system and is within 60 feet of a private water supply wall, The system has a septic tuLk and&oil absorption system and is less than 100 toot but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and-volatile organic compounds indicates that the well is free from pollution from that facility,and the presence of ammonia nitrogen and nitrate nitrogen is equal to or lass than b ppm. 3) OTHER (revised 11103195) Z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinuod) Proporty Address: 105 Hickory Hill Circle Osterville,Mass . 02655 Owner. Andria White Date of Inspeotion:4/1 9/96 D) SYSTEM FAILSs aI have determined that the system violates one or more of the following failure criteria as deflried in 310 CIkR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be aecarswy to correct the b4lurs. Backup of sewage into facility or system oomponent due to an overloaded or clogged SAS or cesspool. �! Discharge or ponding of effluent to the surface of the Eround 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 J21 0 Liquid depth in eeaepeel-it less than 6"below invert or available volume is less than V2 day flow. Roquirod pumping more tl:an d times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 foot 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. A+ Any portion of a cesspool or privy is within 60 feet of a private water supply well. Any portion of a cesspool or privy is loss than 100 foet but greater than 60 feet from a private water supply well with no aoceptabls water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system terns a facility with a design flow of 10,000 gpd or greater(large System)and the system is a sigul5cant threat to public health and safety and the environment bocause one or more of the following conditions exist: (Ll 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 Aroa MA)or a mapped Zone II of a public water supply well) The owner or operator of any such system sha.1 bring the system and facility into hill compllazu with the powiAn Ur tnatmsut progroutt requirements cf 314 CMR 5.00 and 6.00. Plme consult the local regional office of the Department for father information, (revised 11/93/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddresa: 105 Hickory Hill Circle Osterville ,Mass. 02655 Owner. Andria White Date of Inspection:4/1 9/9 6 Check if the following have been done: zI pumping information was requested of the owner, occupant, and Board of Health. Yone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates d N . that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A facility or dwelling was inspected for signs of sewage back-up. ,,, The system does not receive non-sanitary or industrial waste flow The site was inspected for signs of breakout. AII system components,� Yuding the Soil Absorption System,have been located on the site. ZTh"septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. , The size and location of the Soil Absorption System on the site has been determined based on existing information or a proximated by non-intrusive methods. , The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 105 Hickory Hill Circle Osterville ,Mass . 02655 Owner. Andrea White Date of Inspection:4/1 9/96 FLOW CONDITIONS RESIDENTIAI: Deign Jlow:--jjja na Number of bedroo Number of current residents• Garbage grinder(yes or no):5 Laundry connected to system(yes or no):5 Seasonal use(yes or no): NO — Water meter readings,if available: Cj �- � = 5 o7'D 6� 1 - Last date of occupancy:_ COMMERCIAL NDUSTRI ,L- Type of establ nt: AM �' a Design flow: ons/day Grease trap present: (yes or no).10 Industrial Waste Holding Tank present: (yea or no)W Non-sanitary waste discharged to the_Title 5 system: (yes or no)A Water meter headings,if available: A) Last date of occupancy: OTHER(Describe) Last date of occupancy: A GENERAL INFORMATION PUMPING RECORDS and so of information: /1&4�1 a System pumped as part of inspection: (yes or no) S If yea,volume pumped: ons / Reason for pumping: _ Y V t*'1 f Sly�i/�/s TYPE 0 SYSTEM All Septic tank/distribution box/soil absorption system _Av_ Sinsw spool Al0 Overflow cesspool 4C1 Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) �PRO MATE�1(3E of all lccoommpon�ts,date (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)40 (revised 11/03195) 5 r - • SEWERAGt f tKM/I I Nu. I LOCATION: r v� ic•�n y f - VILLAGE:- /o INSTALLER'S NAME: ADDRESS• BUILDER'S NAME & APDRESS: . r DATE PERMIT ISSUED. ' 6 f DATE COMPLIANCE ISSUED: 1 ------ - � zq •f yi °Ln • � J'ri GR/odct . - - - ... i/ 1 SEWERAGE PERMIT N0. c� LOCATION: VILLAGE: f INSTALLER'S NAME: ADDRESS 1 BUILDER'S NAME & F�DDRESS: �� ��Yetl/y r DATE PERMIT ISSUED: ' A' YX q DATE COMPLIANCE ISSUED: O 1 f ` D r .t' 40 a b . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 105 Hickory Hill Circle Osterville,Mass. Owner. Andria White Date of Inspection:4/19/96 SEPTIC,TAM-,J ✓i GWY4k'V s (locate on Site plan) (I Depth below grader Material of construction: concrete_metal_FRP_other(ezplain) Dimensions I Sludge deptl.: Distance frcm top of sludge to bottom of outlet tee or baffle: Scum thickness:r_ Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baMe:-Q_ Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.). Pump tank annually: Garbage disposal is present: Inlet & out let tees are in pjace ,The s lc gound ;Tank abows no Gi un4 of l PakaQP Tn rpDa,re a-re naeaerl :Li me GREASE TRAP:A,11/ttv (locate on site plan) Depth below grade: 10 Material of construation:/J.Aeoncrete_metal_FRP_other(ezplain) sDA Dimensions: N A Scum thickness:7_ Distance from top of scum to top of outlet tee or baMe:-&A Distance from bottom of scum to bottom of outlet tee or baffler Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Co4141 (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) Property Address: 105 Hickory Hill Circle Osterville ,Mass . 02655 Owner. Andria White Date of Inspeotion. 4/19/9 6 TIGHT OR HOLDING TANKALNt'C'• (locate on sits plan) Depth below grade: 44 Material of coastructioZV,&ncrste_metal_FRP_other(explain) iq Dimensions:. __. Capacity: & lI ons Design flow: �' ona/day Alarm level: 4 Comments: (condition of inlet tee,condition of alarm and float switches,etc.) ,�� C.n�wtt;NTS DISTRIBUTION BOX:, (locate on site plan) Depth of liquid level above outlet invert:__ Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) Distribution box has evidence o ea age into or out of is time. PUMP CHAMBEI:4kht , (locate on site plan) Pumps in working order:(yes or no)_A2& Comments: (note coadi' n of pump chamber,condition of pumps and appurtenances,etc.) NQ cont (revised 11/03/95) 7 SYSTEM INFORMATION(oontinued) r / PropertyA.ddresa: 105 Hickory Hill Circle Osterville,Mass .02655 Owner. Andrea White Date of Inspeotion:4/19/9 6 SOIL ANOPIMON SYSTEM (SAS)-d (locate an she plea,if posable;excavation not required,but may be approximated by non-intrusive methods) e If not determined to be present,explain: Type: leach1n8 pits,cumber., leaching chambers,number.Q leaching galleries,number,, leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Comments:(note condition of so signs of hydraulic failure, level of ponding,condition of vegetation,etc.) Loam sub soil 2' lean medium sand to 1 ' ;No signs of hydrauilc ai ure • No signs of Donding;All vegetation is normal. No repairs are: heeded a this ti me, See page 8A CESSPOOLS:A j7 0-- (locate on site plan) Number and configuration: N A Depth-top of liquid to inlet invert: A,,A Depth of solids layer. Y1S Depth of scum layer ice)A Dimensions of cesspool: 1J A Materials of construction: MA Indication of groundwater: A)A inflow(owspool must be pumped as part of inspection) AIR Common :(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) VA -,W,4dWrS PRIVY: &IdWe. (locate on site plan) Materials of construction: AIR Dimensions: t39 Depth of solids:— a Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) A)# A)h CaM Mewl-S (revised 11/03/95). 8 S nC- TAyv-.. 4 4a X/5o�vr GGo o15POSAL PIT uLE 2'trxn � I i ! ;fP'• i ,i 1 1" SIDQWALL SoTToM A2eA s I I oo i I ; . : . • _ ' . . . . . . 1 ,. •�GO .�l o•1 b[7 I , . . . �'�rr.•�It� !r p'tv i�4dU ,. . a ;� , � � : 1{1J11.;• PECC.oL "rI0 1 ZATC' Ilu AWJ o(ZLa: [� " 1 • '•' _�_ IT_ _.. -ivf ! DF A: .eAX TER-: .a I.Jt f+4S J �•! I Sri �- i ' !�. : , >vo:�.iae. . �- ��. .:,luo:�,1, ./.. � ,'✓ -I!�j.G�O !i iau 3 r— al 5 nI'T F6:. �D� ' It Top Fwp' =to4� 7T.Q� 14 r f •� :�. .• •'J;Pe I S t9O wu o7— Tt t p .� / . .. 7 , . t 1000 lal IUV. �.�...:. �:. bal.. t'.o • . �a' IPA T� AND. i 11 s ' ; : . ► ' , ' ; :.:..:. : .; 1L' �:. ::: : .: . WLStJa� 1 i ' I !�. •. : : • : : ' � � � i : I CEQ.T I F I G�a �t-oT # PL A�.l Pu Mr Y TµAT T"IE Pc, vSZt SuowU A.I.1' ¢_r-,o I4 'Co AA P L•`(S W I r H TI r,ta. r,MELI 1-4 M& D �S __ ,A�G,�K R JIQL.M6�1T� T�JE t5A2 v� of T-�� AI�iD I S• DT-' J ! • )cATsz) VITW fJ N - F D ' tL�tST� u� t_AI.JTa ,�2vE�ec iS PI-sw 14 I.JOT BdSED ou AU 1". TeOMEQT OePTE�.KVILt..6. AAA.K T►•1,L OFFS4TL 5WOULD I.IOT .766 US2t> APCn I,- A a I Y /►�e I J . '� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) ProPerh'Addre.s: 105 Hickory Hill Circle Osterville ,Mass . 02655 Omer. Andria White Date of Inspection: 4/19/9 6 i SKETCH OF SEWAGE, LOP, OSAL SYSTEM:two permanent references landmarks or benchmarks locate all webs` : 100' Water Company 428-6691 — Centerville Osterville arstons Mills O� , f J'rS Ci��r/cam -�"'— t� r r DEPTH TO GROUNDWATER Depth to Vq=dwates_j_6 i + feet method of determination or approximation: See page 8 A No water encountered at 121 n • + 4 R1 7hn Trstalled o (revised 11/03/95) 9 W f 1 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's. qualifications .as, required-and is-hereby. authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. ` June 8, 1995 Acting Director of the Zion of Water Pollution Control