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HomeMy WebLinkAbout0153 HICKORY HILL CIRCLE - Health 153 Hickory Hill Circle Osterville A = 121 - 076 C No. ol, I ' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in corn ter: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(ppYitatiou for -Misposal *pstrm Construction permit Application for a Permit to Construct( ) Repair(✓Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Add r or Lot No. ,r'7j #1CI,,osl j��J f�e�,e Owner's Name,Address,and Tel.No. T AA Assessor's Map/Parcel 1 2 — -7& V / Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size /G Q5Z2 sq.ft. Garbage Grinder( ) Other Type of Building & ffl ,9 c j No.of Persons / Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) y IYy gpd Design flow provided�f�'g/r y gpd Plan Date 1?"(b`/s Number of sheets Revision Date Title Size of Septic Tank 40i'/N c Type of S.A.S. I Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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. ig e I O Date 2 s Application Approved by Date Application Disapproved y Date for the following reasons s Permit No. --I f2 Date Issued No. � - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in comp ter: s Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(✓Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Addre11 or Lot No. /S ] ���r�/n�� N��� 1 ` Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 2 — 7& V rAA �%7 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms !/� Lot Size /(�Jy'O sq.ft. Garbage Grinder( ) Other Type of Building //�Z),p,.I42 t No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) yYO gpd Design flow provided GZ!5-L/� lam/ gpd Plan Date 6- -! t�-f J Number of sheets - Revision Date Title Size of Septic Tank x/9 f/N Type of S.A.S.Try GG I/an/ Description of Soil Nature of Repairs or Alterations(Answer when applicable) ,L.- aI/,.✓ UJt�� N" 5 hQ rJ P :3 7 f T/7 O'K �2 Of TO c Date last inspected: Agreement: wt 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 operafitnil a Certificate of Compliance has been issued by this Board of Health. i ed ( t' Date t � _ Application Approved by Date -, Application Disapproved y / / Date for the following reasons Permit No. r Date Issued THE COMMONWEALTH OF MASSACHUSETT,S BARNSTABLE,MASSACHUSETTS � ' T Certificate of Compliante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )b I k / ► (0")nJ at <(t i /f L ✓ has been cons t d' ,a cord e with the provisions Title 5 and the for Disposal System Construction Permit No. da Installer,,o,l,,s A Ic>rvn9 I f-C. Designer #bedrooms_y yl") Approved design flow t/ gpd The issuance of ht i ep t shall not be construed as a guarantee that the system wil func ion as desig'ed. Date Inspector �ti / ------------------------ ----- ----------.------------------ ------------------------ ---------------------------------------------- No. ,' / Fee-±! �✓� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE, MASSACHUSETTS Misposal 6pste Construction Vermit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at / 7 IVIC d/u Ali /✓G�P and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:ConstructiMmbjgopleted ithin three years of the date of this permit. Date Approved by TOWN OF BARNSTABLE LOCATION L",q.-i, r 1 fe, SEWAGE# VILLAGE� -,J\qoT ASSESSOR'S MAP&PARCEL J;Q ` L INSTALLER'S NAME&PHONE NO. - N L� SEPTIC TANK CAPACITY is ri�s c LEACHING FACILITY:(type) � � "�E �b (size) NO.OF BEDROOMS OWNER M Jf,pk1y PERMIT DATE: 512(9 COMPLIANCE DATE: S 2 'i Separation Distance Between the: Al a ca-'petc' Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED By j( � r _ floor -,25- - 3S— -46 Aboor Alcove D 2 - 22 T NS. NO.: 4 CITY/TOWN: AP LICANT: ADiDRESS: DE IGN FLOW: y a gpd RENEWED BY: DATE: t� N/A OK NO Le al boundaries denoted 310 CMR 15.220(4)(a)] St r et, Lot, tax parcel number and lot number noted on plan [310 CN; 15.220(4)(u)] Loc, s Provided [310 CMR 15.2204(t)] _ Pla proper scale? (1"=40' for plot plans, 1"=20' or fewer for co ponents) [310 CMR �15.220(4)] Easements shown [310 CMR 15.220(4)(b)] Sys em located totally on. lot served [310 CMR 15.405(1)(a) for upgrades - i not, a variance is required 310 CMR 15.412(4)] _ Location of impervious surfaces (driveways, parking areas etc.) , [31� CMR 15.220(4)(d)] V _ Location all buildings existing and proposed 310 CMR 15.4,20(4)(c)] Location and dimensions;of system components and reserve aree s. [310 CMR 15.220(4)(e)] Sys em Calculations 310 CMR 15.220(4)(0] daily flow septic tank capacity; (required and provided) soil absorption system (required and provided) whether system desi ned for garbage grinder ✓ _ North arrow [310 CMR 15.220(4)(g)] _ Exiting and ro osed contours [310 CMR 15.220(4)(g)] Location and log of deep;observation holes (existing grade el, on eacl i test) [310 CMR 15.220(4)(h)] _ Names of soil evaluator and BOH representative [310 CMR / 15.2�20(4)(h) and (i)]- Location and date of percolation tests (performed at proper elevation?) [310 CMR 151,220(4)(i)] V _ Percolation test results match loading rate? 310 CMR 15.242 _ Certification statement by Soil Evaluator 310 CMR 15.220(4)0)1 Obs rved and Adjusted groundwater(method for adjustment given or indicated) [310 CMR 15.103(3) and 310 CMR 15.2120(4)(n)] Add ess Sheet 1 of 7 t N/A OK NO Location of every water supply, public and private, [310 CMR / 15.220(4)(k) within 400 feet of the proposed system location in the case of surface water sup lies and gravel packed public water supply within 250 feet of the proposed system location in the case Al", within 150 feet of the proposed system location in the case of rivate water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins ✓ eps� located within 50 ft. [310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located [310 CMR 15.220(4) m if water line cross see 310 CMR 15.211 1 1 Profile of system showing invert elevations of all system components and the bottom of the SAS 310 CMR15.220(4)(o)] Stamp of designer [310 CMR 15.220 1 and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor (required if construction activities within 5 ft. of lot line) [310 CMR 15.220 3 Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2) or as approved for an u Trade under LUA at 310 CMR 15.405 1 k ] Test hole adequate to demonstrate four feet of suitable material? [310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? LI/ [310 CMR. 15.103 3 ] Benchmark within 50-75' of system 310 CMR 15.220(4)(g)] Materials specifications noted? [various sections of 310 CMR 15.000] System components not> 36" deep (unless Local Upgrade Approval or LUA requested) [310 CMR 15.405(1(b)] .C cxv\,- Address__ Sheet 2 of 7 N/A OK NO } S�r,3ri �T-:M—a� e ? S] 1.?lY rn i axe k " t•� .YS P.r--F4�..e Siz OK? [310 CMR 15;223(1)] Inlet tee located ten inches below flow line 310 CMR 15.227(6)] Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR 15.227(6)] Out et tee with gas baffle or approved filter [310 CMR 15.227(4) Not regarding installation on stable compacted base [310 CMR 15.228(l)] Separation between inletand outlet tees (no less than liquid dep h) [310 CMR 15.227.(2)] Inlet/Outlet elevations a0east 12" above high groundwater (exlept as described 310CMR 15.227(5)) or permitted for upgrades under LUA 310 CMR 15.405 1 (k) Minimum cover 9" (Tanks buried more than 9" must have risers on E 11 openings and on the d-box) [310 CMR 15.2228(1) and 310 CMP, 15.232(3)(0] Thr e access covers (inlet and outlet must be 20" or greater) - mi dle access at least 8" (by 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade - one port for systems<1000gpd, two fors stems >1000 gpd [310 CMR 15,228(2)] All at-grade covers secured to unauthorized access? [310 CMR ✓ 15.228(2)] > 1 Q ft from building foundation [310 CMR 15.211(1)] Buoyancy calculation Required/Done [310 CMR 15.22 L(8)] H-20 Where a ro riatO, 310 CMR 15.226(3)] Setbacks from resources 310 CMR 15.211] Mu t� $Co�m`art=ment T�aatiks � � �` Mal.5.,n.. .rx_......• '5....,... ...�n_�<�iE.2.r.xf_...z£ ..P e u n._,_._a..__. x,_..._. Re ired when other than single-family dwelling or flow>1000 g d [310 CMR 15.223(1 (b)] Firs I compartment 200%!daily flow; Second compartment 100% daily flow [310 CMR 15.'224(2) and (3)] "U" pipe through or over'baffle, outlet of each compartment with as baffle or approved filter 310 CMR 15.224(4)] Addi ess Sheet 3 of 7 t N/A OK NO BUTLD�Il\GSESRA1�ID pT �V2�T� ._sPI1G� � �� .. _� Located at least ten feet from any water line? [310 CMR 15.222(2)] Disposal piping at least 18" below water line (when water and sewer cross, see 310 CMR 15.211 1 1 Cleanouts required/provided ? 310 CMR 15.222(8)] t/ Thrust blocks specified in force mains? 310 CMR 15.221(6)(c Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable 4 [310 CMR 15.222(6 Proper pitch on all runs? (.005 within gravity-distributed trenches and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)] Siphonproblem/ leachfreld below pump chamber Endca s or vent manifolds specified? Size and orientation of discharge holes specified? (not smaller than 3/8" riot larger than 5/8") [310 CMR 15.251(8) and 310 LX CMR 15.252(2)(h ] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed D3IS'TRIia3( T�I l'A" ON BOX ` s 3 .. �����_ _ Stable compacted base [310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.223(3)(a)] Riser if deeper than 9" 310 CMR 15.232(3)(0] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sum 6" [310 CMR I5.232(3)(e)] Watertight:cover if<2000gpd); waterproof manhole if>2000gpd [310 CMR 15.232(3)(d)] �� PU11IrP I Capacity (emergency storage above working=design flow)? [310 CMR 231(2)] Proper setbacks [310 CMR 15.211 same as septic tanks)] Watertight:20-in minium access manhole at least 20" MUST BE TO GRADE 310 CMR 15.231(5)] Service components accessible (not too deep with piping, disconnects accessible Alarm floats - alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15,231(6) and (8)] Stable Compacted Base [310 CMR 15.221(2)] Buo anc calculations needed ? Provided? 310 CMR 15.221(8)] Address Sheet 4 of 7 f i .. N/A OK NO �gT Igg .�„ Cal,ulations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1)] Rec uired separation to groundwater? [310 CMR 15.212)] Aggregate specified as double washed [310 CMR 15.247(2) Sys em Venting required%provided? (system under driveway or >36" deep) 310 CMR 15.2411 Inspection ports specified and within 3"final grade? [310 CMR 15,240(13)] BrI kout requirements met? (No violation of breakout elevation within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and Guilidance Document Chambers and Gal. in trench configuration supplied with inlet ✓, eve.y 20 ft. [310 CMR 15.253(6)] Eac structure with one inspection manhole (if>2000 gpd must be to grade) [310 CMR 15.253(2)] A re ate 1' minimum- 4' maximum. [310 CMR 15.253(1)(b)] 2' sidewall credit maximum [310 CMR 15,253(1)(a)] In bed configuration, inlet every 40 sq. ft. [310 CMR 15.253(6)] Wic th 2' minimum 3' maximum [310 CMR 15.251(1)(b)] . 100 feet- maximum len nth [310 CMR 15.251(1) a ] Minimum separation 2x effective depth or width whichever �J/M re4ter(3x if reserve between trenches) [310 CMR 251(1)(d) Situated alongcontours 310 CMR 15.251(2)] Bre kout OK? [310 CMR 15.211(1)[4] and Guidance Document] BESAS1Vlaximaumse 4W. _ min Lmum 2 distribution lines [310 CMR 15.252(2)(a)] Maximum separation between lines 6' 310 CM R15.252(2)(d)] Ma imum separation between lines and outside of bed 4' [310 ` CMR 15.252(2)(e)] Ag regate depth below discharge pipes 6" minimum, 12" ma imum. [310 CMR 15:.252(2)(g)] Sep iration between beds l0' minimum. [310 CMR 15.252(2)(f)] Bot orn area used in calculations only [310 CMR 15.252(2)(i)] Addi ess Sheet 5 of 7 e N/A OK NO �x'm# D'TD 3THkE PLAN TI ULyL � s � � ` 11 _.-,__� _- .. Pressure Dosed System ? Provided pump and piping calculations as required [310 CMR 15.220(4)(r)] M7 Pressure dosing required on all systems >2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A Remedial Use Approvals] If used in gravelless system - make sure jet is directed as not to scour soil interface [Guidance Document] Inspections once per,year (systems<2000 gpd) or quarterly (>2000gpd) good to note on plan [310 CMR 15.254(2)(d)] Construction in fall - Did the plan specify that the fill shall meet the specification of 310 CMR 15.255 3 ? Impervious barrier and/or retaining all ? [Guidance Document] Impervious barrier installation must be supervised by designer [310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer [310 CMR 15.255(2)(a)] Side slope not exceed 3:1 ? [310 CMR 15.255(2)] Breakout requirements met? [310 CMR 15:252(2) and Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. recommended) [310 CMR 15.255 (2)(e)] Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scour soil interface Alterauatave=Se,tac S stem 1/�A r royal Letters z. , - � -T ,. . ... -.. �F,. .. Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a copy of a maintenance Are the variances listed on the plan ? [310 CMR 15.220 4 RLS Stamp necessary on plan if a component is within five feet of 2roperty line [310 CMR 15.412(4)] New construction or increased flow proposed - [Refer to 310 CMR 15.414] l/ Address Sheet 6 of 7 l N/A OIL NO NatrogensSensataveAreas41 §, 1a. a Is t e system in a Designated Nitrogen Sensitive Area(Zone II for a public supply well)? [310 CMR 15,214, 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such 20 exi ting systems] Is the system proposed on the same lot as served by private well ? [31 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR 15. 16(1)] ✓� Pumping to septic tank ? [ 310 CMR 15.229] Shared System [310 CMR 15.290] 7 Addi ess Sheet 7 of 7 TOfi, of Banstable �arTHE Two Regulatory Services ; Richard V. Scali, Interim Director ` BARNSTABLE, 039 � Public Health Division , ?°o � Thomas McKean,Director 200 lain Street,Hyannis,MA 02601 0 e: 508-862-4644 Fax: 508-740-6304 Installer & D�signe 'CeA f cation Forin . Da e: .� ' ' Sewage Permit# �c�i5- I -3 Assessor's Ma-pTarcel 'Fe Al M c De igner". CY,�;,n n —LpajqrL&$ \sib, Installer: `C7.A . '(S �C .a Ad Tess: +Z w', Cvr-ossP,-e.to( �2d. Address: t®• !tP*K t4 S'" On 5-9-G D , Sc",x Ivvc was issued a permit to install a (date) (installer) ` se` is system at S 3 i c o ry I G i based on a design drawn by 7e l e r- Nt c Cn � (ad ress) ` E P i v I106 t lv%c, dated 5- Wt R 5—, - (d�sgner) I certify that the septic system referenced above was installed substantially according to the design, which may include minor, approved"changes such as lateral relocation of the distribution box and/or septic'tank.® .,Strip out (if required) was inspected .an(J. the soils were found satisfactory. `. I,certify that the septic system referenced _bdvc was installed with major. cha.Mges (i.e. greater than 10'' lateral relocabbia of the SAS bj- any-vertical relocation of any`component ` of the septic systezn),Ibut in accordance With State & Local.Regulatiosis: Plan revision or certified as-built by designe'to follow: Strip out (if required) ras.inspected:and the soil' were found satisfactory. w I+AAA I certify that the system referenced above was constructed jr�-`Tianoe..with the terms of the IAA approval letters (if applicable) t S'1 �r':eGIY7�of» q er's Sgn iature) ,,tdo WA00 y _ dl (Designer's Signature) .(l�ffix:Designers Stamp Here) P ASE RETURN TO BARNSTAB;[:,E_PUB LIC EXALTH DMSION. CERT FICA'TE` : 011 CONEPLIANCE WILL NOT BE ISSUED UNTIE BOTH TIRS. FORM AND A& B ( T CARD ARE RECEIVED BY TBE BA.:RNS'TABLE PUBLIC HEALTH D IVISION. TF ANJES._YOU. Q:j p esigner Certification Form Rev 8-14-13.doc ' r ll - 1 �91 oF Town of Barnstable P# INE. . Department of Regulatory Services BARNSCABLE, Public Health Division Date -Z' Q' q MAss. mY 9Qj i679• ��� `. v �200.Main Street,Hyannis MA 02601 - i Date Scheduled ' Time U ; Fee Pd. _ wq " Soil Suitability.Assessment or Sew e osal, tY• .f �sp Performed By: Ste'—l l Z Witnessed By: r LOCATION GENERAL INFORMATION& G ORMATION Location Address j� , )4 Sp y / _ Owner.'s Name /Z t C kq& N,4—p� I Os-Le,'-`s ` �e Y� k Address,. J k f�"lovj {{fl Cyr c-lr< i girl�-L /4 n 0z&55 n. II Assessor's Map/Parcel:,,1 1 b? f`p,: •# ;y " < -Engineerr'sName KJ•,n � .�-t � NEB W CONSTRUCTION REPAIR Telephone#. 7-7 —53) Land Use Slopes(%) Z— Surface Stones' ��� r 8 '. Distances from: Open Water Body73� 'ft Possible Wet Area 72� ft Dunking Water Well ft Drainage Way N/A- ft Property Line ft Other ft ! SKETCH: Street name,dimensions of lot,exact locations of test holes&perc tests locate wetlands inr proximity to holes 314 i Pro t L . Parent material(geologic) O�°�`�.� —Depth to Bedrock V t Depth to Groundwater: Standing Water in Hole: / (A- Weeping from Pit Face 9V J11� u Estimated Seasonal High Groundwater > DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth,to soil mottles in. i Depth to weeping from side of obs.hole: _ in. Groundwater Adjustment ft. iindex Well;! Reading pate._� Index Well level Adj.factor----- Adi.Groundwater Level PERCOLATION TEST Date Time Observation Hole# - � Time at 9" Depth of Pere. 5q 7tZ-- Time at 6" Start Pre-soak Time @ t0 z3 _ Time(9"-6") End Pre-soak Rate Min./Inch' I . Site Suitability Assessment: Site Passed L-11111 Site Failed: Additional Testing Needed(YIN)_— Original: Public Health Division Observation Hole Data To Be Completed on Back:-----••---- ***If'percolation test is to be conducted within 100' of wetland, you must first notify the i Y Y Barnstable Conservation Divisi,4�i at least one (1) week prior to.beginning. (V Q:\SEPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# l pth from Soil Horizon Soil Texture .Soil Color Soil. Other Surface(in.) (USDA) (Munsell) Mottling '(Structure,Stones;Boulders.. Consisteacy.% v _cooJ2 01 f -43$ M42.0L s0.1A 2,15 -/y DEEP OBSERVATION HOLE LOG Hole# '2-- Eepth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,.Stones,Boulders. Consistency, rave a -Z(o ri LL N 38 c, dl s z-s-Y 14 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color ' Soil Other Surface(in.) -• (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. Gravel). i C - I DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA). (Munsell) Mottling (Structure,Stones',Boulders. Consistency. Oravel). Flood Insurance Rate Ma : Above 500 year flood boundary No�_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No X, Yes Depth of Naturally O.ccurrine Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the ai ea proposed for the soil absorption system? _— If not,what is the depth of naturally occurring pervious material? Qertiiseation I certT that on �l �W��_(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 . e required training,expertise and experience described in 310 CMR.15.017.1 S gnature �� Date Q\SEPTICTERCPORM.DOC t. a' Commonwealth of Massachusetts kvTitle 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments trw 153 Hickory :Hill Circle Osterville MA Property Address Richard H Murphy JR 153 Hickory Hill Circle Owner Owner's Name information is Osterville MA 02655 /11 a 0I3 required for every page. Citylrown 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 A. General Information filling out forms on the computer, I use only the tab 1. Inspector: Joe Martins key to move your cursor-do not ACCu Sepcheck use the return Name of Inspector key. S. Dennis, MA 02660 ,y Company Name Company Address , City/Town 50 • ^ 0��b State S I L/ 7 Zip Code Telephone Number s 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: U/Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Insp o Signatu 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 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. ****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 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 d I 3 . f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 153 Hickory Hill Circle 'Osterville `MA Property Address chard H Murphy JR 153 Hickory Hill Circle Owner Owners Name information is required for every Osterville MA 02655 1/12/2013 page. Citylrown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: �ave not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to replaced or repaired. The system, upon completion of the replacement or repair, as roved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the followin atements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic to whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltratior or to ailure is imminent. System will pass inspection if the existing tank is replaced with a comply septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is I than 20 years old is available. ❑ Y ❑ N ❑ (Explain below): a a T 1 t5ins•11110 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r' 153 Hickory Hill Circle Osterville , MA Property Address chard H Murphy JR 153 Hickory Hill Circle Owner Owner's Name requiratifore Osterville MA 02655 1/12/2013 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cunt.) 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/pis) g more than 4 times a year due to broken or obstructed pipe(s). The system will f(with approval of the Board of Health): ❑ broplaced ❑ Y ❑ N ❑ ND(Explain below): obsed ❑ Y ❑ N ❑ ND(Explain below): f k C) Further Evaluation is Required by the Boa of Health: ❑ Conditions exist which require further ev ation by the Board of Health in order to determine if the system is failing to protect public alth, safety or the environment. 1. System will pass unless Bo d of Health determines in accordance with 310 CMR 15.303(1)(b)that the system ' not functioning in a manner which will protect public health, safety and the environme : ❑. Cesspool or vy is within 50 feet of a surface water ❑ Cesspo or privy is within 50 feet of a'bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 t , Commonwealth of Massachusetts _ - F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments kzv 153 Hickory Hill Circle Osterville MA Property Address Richard H Murphy JR 153 Hickory Hill Circle Owner Owner's Name information is Osterville MA 02655. 1/12/2013 required for every page. Cirylfown Sate Zip Code Date of Inspection B. Certification (cont.) 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. ❑ The system has a septic tank and SAS and the SAS is within a Zon of a public water supply. ❑ The system has a septic tank and SAS and the SAS is wit ' 0 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less an 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance- ' **This system passes if the well water analysi , performed at a DEP'certified laboratory, for fecal coliform bacteria indicates absent and the p sence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no o er failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All 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 0 r clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters y due to an overloaded or clogged SAS or cesspool . 'El or liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6",below invert or available volume is less than 1/day flow t5ins•11110 A Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 4 of W t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 153 Hickory Hill Circle Osterville MA Property Address Richard H Murphy JR 153 Hickory Hill Circle Owner Owner's Name information is Osterville MA 02655 1/12/2013 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ' El obstructed pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ( Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. . ❑ �S 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.] ❑ r�fi The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ,_,{ The system fails. I have determined that one or more of the above failure y� 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 d to 15 000 d. 9 gP gp For large systems, you must indicate either"yes" or"no"to each of the fol owing, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 f of a surface drinking water supply ❑ ❑ the system is i n 200 feet of a tributary to a surface drinking water supply ❑ ❑ the syst is located in a nitrogen sensitive area(Interim Wellhead Protection Are IWPA)or a mapped Zone 11 of a public water supply well If you have answer yes"to any question in Section E the system is considered a significant threat, or answered"ye in Section D above the large system has failed. The owner or operator of any large system cons red a significant threat under Section E or failed under Section D shall upgrade the system i ccordance with 310 CMR 15.304. The system owner should contact the appropriate regio office of the Department. t5ins•1 V10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Hickory Hill Circle Osterville MA Property Address Richard H Murphy A -153 Hickory Hill Circle Owner Owner's Name information is Osterville MA 02655 1/12/2013 required for every page. Citylrown 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 2/ ❑ 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? 21 ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) , ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of br ak out? m G Were all syste components, ez n the SAS, located on site? ❑ .Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? ` The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ( ❑ Existing information. For example, a plan at the Board of Health. ry, ❑ Determined in the field(if any of the failure criteria related to Part C is at issue l approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Pr �. . Residential Flow Conditions: l Number of bedrooms(design): Number of bedrooms(actual): l DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): —�—i- . - t51ns-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of V ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9wi 153 Hickory Hill Circle Osterville MA Property Address Richard H Murphy JR 153 Hickory Hill Circle Owner Owner's Name information equiredio re Osterville MA 02655 1/12/2013 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: - D Ilia Number of current residents: —+ Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes No Laundry system inspected? Yv 4- ❑ Yes ❑ No Seasonal use? ❑ Yes '❑l No Water meter readings, if available(last 2 years usage(gpd)): f �— Detail: C20 d1 3 Sj 0 0 0 ! q/ Sump pump? ❑ Yes No Last date of occupancy: Dat Z 3 Commercial/Industrial Flow Conditions: Type of Establishment: - Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank ? ❑ Yes ❑ No Non-sanitary was Ischarged to the Title 5 system? ❑ Yes ❑ No Water teeter readings, if available: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 7 of 17 �. _<L\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r' 153 Hickory Hill Circle Osterville MA Property Address Richard H Murphy JR 153 Hickory Hill Circle Owner Owners Name information is Osterville MA 02655 1/12/2013 required for every page. CV/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information ` Pumping Records: q 2 3 0R0/01 P/scovnf P Source of information: L',�aat .Xlue W'gk#1 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, ution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool F ❑ 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): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Hickory Hill Circle . Osterville MA Property Address chard H Murphy JR 153 Hickory Hill Circle Owner owner's Name - information is required for every Osterville MA 02655' 1/12/2013 page. city/Town State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site? ❑ YeSX No Building Sewer(locate on site,plan): Depth below grade: feet Material of construction: ❑cast iron X40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): a L� A) 6 Septic Tank'(locate on site plan): . Depth below grade: feet Material of construction: LXI 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: 11 0 X 11 Sludge depth: 41 -a kAter ©tiler ' t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts a. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r' 153 Hickory Hill Circle Osterville MA'. Property Address ' Richard H Murphy JR 153.Hickory Hill Circle Owner Owner's Name information is required for every Osterville MA 02655 1/12/2013 page. Cityrrown State . Zip Code Date of Inspection D. System Information (cont.) �� „� a�f(��e•� Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle / Scum thickness ell Distance from top of scum to top of outlet tee or baffle Distance from bottom of scam to bottom of outlet tee or baffle ,( /� // How were dimensions determined? -- R Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): nn Z, 42 ve i( ho/-A acl-fle.7 &4w947S Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass olyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of m to top of outlet tee or baffle } Distance f ttom of scum to bottom of outlet tee or baffle Date of last pumping:- Date t5ins•11/10 TItle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 _ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposals System Form-Not for Voluntary Assessments 153 Hickory Hill Circle Osterville MA Property Address chard H Murphy A 153 Hickory Hill Circle Owner Owner's Name information is Osterville MA 02655 1/12/2013 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be p ped at time of inspection)(locate on site plan): Depth below grade: Material of construction: [I concrete metal El fiberglass ❑polyethylene ❑ other(explain): Dimension Capaci gallons Design Flow gallons per d Alarm present: ❑ Y ❑ No Alarm level: /itches, in working order: ❑ Yes ❑ No Date of last pumping: Comments(condition of alarm and flo 7 Attach copy of c rent pumping contract(required). Is copy attached? ❑ Yes ❑ No 't5ins 11/10 Title 5 Official Inspection Form:Subsurface Selvage Disposal System•Page 11 of 17 _ p, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments' 153 Hickory Hill Circle Osterville MA Property Address chard H Murphy JR 153 Hickory Hill Circle Owner Owner's Name information is required for every Osterville MA 02655 1/12/2013 page. citylrown State Zip Code Date of Inspection D. System Information (cont.) 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.): OX �Ps�� f` Pump Chamber(locate on site plan): • i Pumps in working order: Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chambe , condition of pumps and appurtenances, etc.): f Soil A/orption System(SAS)(locate on site plan, excavation not required If SAS not located, explain why: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 c Commonwealth of Massachusetts vwiTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Hickory Hill Circle Osterville MA Property Address chard H Murphy A 153 Hickory Hill Circle Owner Owners Name information is required for every NIA .A 02655 1/12/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Type: A leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): X�P 14Sl 4 'L ) V Ve N 'P dPPY D c oj e. 7- 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 constr ction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 153 Hickory Hill Circle 1�Osterville MA kilv; Property Address Richard H Murphy A 153 Hickory Hill Circle Owner Owner's Name information equiredio re Osterville MA 02655 1/12/2013 required for every page. City[rown State Zip Code Date of Inspection 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: Dimensions . Depth of solids Comments(note condition soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•1 V10 ` Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form QMW Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Hickory Hill Circle Osterville MA o _ Property Address Richard H Murphy JR 153 Hickory Hill Circle Owner Owners Name information is Osterville MA 02655 1/12/2013 required for every page. City/row n State Zip Code Date 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 ° 3 t5ins•11/10 Title 5 Of vial Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewa a Dis osal System Form -Not for VoluntaryAssessments p 1T3 H ickory Hill Circle Osterville MA Property Address Richard H Murphy JR 153 Hickory Hill Circle Owner Owners Name information is Osterville MA 02655 1/12/2013 required for every page. City[Town State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: y [Check Slope Surface water N/0I heck cellar []�Shallowwells �f Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150.feet-of SAS) Checked 'th local Board of Health-explain: 17 C /HS d✓ ' ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed U'SGS database-explain: Youl must describe how you established the high ground water elevation: Y- 7 .)-oo k 1111w ?q C 4�rj' 5-_ EeLAqhok. Mo > l3 -7r — 71 rS .3 Z.(o Before filing this Inspection Report, please see Report Completeness Checklist on next page. , t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Hickory Hill Circle Osterville MA w -,4f Property Address Richard H Murphy JR 153 Hickory Hill Circle Owner Owners Name information is Osterville MA 02655 1/12/2013 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked inspection Summary D(System Failure Criteria Applicable to All Systems)'completed [j�-System Information-Estimated depth to high groundwater [Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file e. a�, � ' .. ' as e a a • r • -•� � _ . • r t5ins'-11/10 - - - TPoe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17' p _ 4, •o. Commonwealth of Massachusetts _ Title 5 official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 153 Hickory Hill Road \ CDUC Property Address r f Dale Urbanik Owner Owner's Name information is Osterville MA 02655 07/29/2008 required for every page. City/Town State Zip Code Date of Inspection Inspection results must besubmitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Brad J. White cursor-do not Name of Inspector t use the return Bluewater I key. - Company Name 350 Main Street ` Company Address s. West Yarmouth MA 0J 673 .97- City/Town State aziiip Code _0 0 (508)775-2800 f Telephone Number License Number t.> 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. I am a.DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: © Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority _.. 07/29/2008 Inspector'rem nature Date The sysinspector 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. ****This report only describes conditions at the time of inspection and.under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 15 N / ~ f t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Hickory Hill Circle Property Address Dale Urbanik Owner Owner's Name information is required for Osterville MA 02655 07/29/2008 every page. City/Town State 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 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: w System fully meets pass criteria.Tank was pumped after inspection.. 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. Answer yes, no or not determined (Y, N, ND) in the❑ for the following statements.If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or 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. ND Explain: ❑ 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 t5insp:doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 /�X Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t M 153 Hickory Hill Road Property Address Dale Urbanik Owner Owner's Name information is Osterville MA 02655 07/29/2008 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ 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: 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. ❑ 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. t5insp.doc-03/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Hickory Hill Road Property Address Dale Urbanik Owner Owner's Name information is required for Osterville MA 02655 07/29/2008 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont:) C) Further Evaluation is Required by the Board of Health(cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis,.performed at a DEP certified laboratory, for coliform bacteria 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 All Systems: You must indicate"Yes"'or"No".to each of the following for all inspections: Yes No ❑ 6/ 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 ElStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool' . ❑ �/ Liquid depth in cesspool is_less than 6" below invert or available volume is less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or ❑ 62 obstructed pipe(s). Number of times pumped: ❑ ( Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ I Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp.doc+03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Hickory Hill Circle Property Address Dale Urbanik Owner Owner's Name information is required for Osterville MA 02655 07/29/2008 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply / well. ElL� 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 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 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 . E] ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ 0 the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public.water supply well 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. t5insp.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments M 153 Hickory Hill Road Property Address Dale Urbanik Owner Owner's Name information is required for Osteryille MA 02655 07/29/2008 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 EZ'* ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ E( Were any of the system components pumped out in the previous two weeks? ❑ E?( Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ❑ Were as built plans of the system obtained and examined? (If they were not available note as.N/A) E�' ❑ Was the facility or dwelling inspected for signs of sewage back up? M ❑ Was the site inspected for signs of break out? ❑ Were all system components, �the SAS, located on site? 2f ❑ 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? f The size and location of the Soil stem Absorption S SAS on the site has p y (SAS) been determined based on: ❑ Existing information. For example, a plan at the Board of Health. Determined in the field (if.any of the failure criteria related to Part C is at issue. ®/ El approximation of distance is unacceptable) [310 CMR 15.302(5)]" t5insp.doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 153 Hickory Hill Circle Property Address Dale Urbanik Owner Owner's Name information is required for Osterville MA 02655 07/29/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Unknown _ Number of current residents: 0 Does residence have a garbage grinder? ® Yes 12 No Is laundry on a separate sewage system? [if yes separate inspection required] ® Yes JO No Laundry system inspected? ® Yes ® No Seasonal use? ® Yes No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ® Yes ® No Last date of occupancy: Approx 2 monthsDate Commercial/Industrial.Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? - .Yes No Industrial waste holding tank present? ® 'Yes ® No Non-sanitary waste discharged to the Title 5 system? ® Yes ® No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Hickory Hill Circle Property Address Dale Urbanik Owner Owner's Name information is required for Osterville MA 02655 07/29/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont) General Information Pumping Records: Source of information: After Inspection Was system pumped as part of the inspection? ® Yes ® No 1,000 If yes, volume pumped: gallons How was quantity pumped determined? Tank size Reason for pumping: Check tanks structural integrity Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy El `WO') Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known) and source of information: ----v* When the system was installed is unknown, no information on file at board of health. Were sewage odors detected when arriving at the site? ® Yes ® No t5insp.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 153 Hickory Hill Circle Property Address Dale Urbanik Owner Owner's Name information is required for Osterville MA 02655 07/29/2008 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: © cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/Afeet Comments(on condition of joints, venting, evidence of leakage, etc.): Building sewer is in good condition. No evidence of leakage. Used camera to check piping. , Septic Tank(locate on site plan): Depth below grade: 911 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 ------------------------------------------------------------------------=------------- ------ 1,000 gallons Dimensions: 711 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29" 4„ Scum thickness 711 I. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet e or " ut et e t baffle 16 How were dimensions determined? Measured I . t5insp.doc•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Hickory Hill Circle Property Address Dale Urbanik Owner Owner's Name information is required for Osteryille MA 02655 07/29/2008 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee is cast iron and in good condition.Two outlet lines leaving septic tank one on each end, both have concrete baffles. No evidence of leakage in or out of tank. 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 Comments(on pumping recommendations, inlet and outlet tee 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 ❑imetal ❑fiberglass ❑ polyethylene ❑other(explain): i t5insp.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Hickory Hill Circle Property Address Dale Urbanik Owner Owner's Name information is required for Osterville MA 02655 07/29/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert N/A 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 t5insp.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,. 153 Hickory Hill Circle Property Address Dale Urbanik Owner Owner's Name information is required for Osterville MA 02655 07/29/2008 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site.plan, excavation not required): If SAS not located, explain why: Type: leaching pits number: so 2 @ 6'x 6' ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number; length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil is dry. No signs of hydraulic failure. Vegetation is normal. Pit A(original)9"from pipe to water. Pit B (precast)3'-2"from pipe to water: t5insp.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts : . Title 5 Official Inspection Form` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Hickory Hill Circle Property Address Dale Urbanik Owner Owner's Name information is required for Osterville MA 02655 07/29/2008 . every page. Cityrrown State y Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number.and configuration Depth—top of liquid to inlet invert Depth of solids layer , Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ® Yes ® No Comments(note condition of soil, signs of hydraulic failure, level of'ponding, condition of vegetation,. etc.): 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.): t5insp.doc-03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 15 c Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 153 Hickory Hill Circle Property Address Dale Urbanik Owner Owner's Name information is required for Osterville MA 02655 07/29/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal Sys m: Provide a sketch of the sewage disposal system including ties to at least two permanent refere a landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water suppl enters the building AtNZ . 2%aii �aVF WAY I cAl 3�r- zip' 3 r '4 40 A A aFAX 0 � •,oo cp�r�� f I >,d l � S\F"LF Uw) t5insp.doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 NOT I O SEAL I Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments - ,M 153 Hickory Hill Circle Property Address Dale Urbanik Owner Owner's Name information is required for Osterville MA 02655 07/29/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑✓ Check Slope ❑✓ Surface water © Check cellar ❑✓ Shallow wells Estimated depth to high ground water: 13'-9"+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: Well MIW 29/Zone C/Level 8.2/Adjustment 3.3 x 12"=39.6" You must,describe how you established the high ground water elevation: Bottom of the deepest leaching pit is at 93". Hand augeered in an area about a foot lower than the leaching pit to a depth of 165"with no indication of groundwater. If you add the required usgs adjustment of 39.6"brings the total to 132.6".This leaves an additional 32.4"of seperation.. t5insp.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 I ! I I ! j � —� ! ) ! i i I I ; � ! j I I 1 i i L..__.I I } I _f_ _I_ .i_ j . I L. _I .I-. ! � � •` ` 1 }}11 I , ;- ,_._..._�_.._._ ._.. f .-:.._ —i _.�. -__ _._ _ )....._..� ....�_.._._ __ ,_ ......� __.�_-. + TI,. ..._i..,_._.! .__ _-! ^. __"-i ..._ ... ' -_..I•_..__ 'bay. `.�:.1 a.._. ... I _._..._. t.:•J.� —� _ t t t t ; I I , ; j � i�r`� -!- � ' at.I�_��•A I i � I ��i �_ I I i s I ; I � t •� a I q , �F' I_.. r o , i , i I I j I � i I I t i i I�. I i j�' � ` _.I--'--- 1 I I� �•.l• I �-..'... I ( - ! .'� _ Ouc a4 I �1 I } ,I I I I ! I I i. i I ! !_ _, _ ; . ► ! ; - I I i I _ � i i I ; i ' J ,. i � I t f ; I j , I— !_ !_.. ' '- — L _ 1__ I _ �r '—! ! IC? -- � LI1.C_.4. .'. f I --- --—I— — — --- — — --- — I I IL — i I I• I I i I '— ! I ' I ! --I---_-j � I I■j I I I I ! I I i �I _ ! I i t � , � I I 1 , I I I I -I _. _ I_ (_ I ..'__ ' _..!-_— c I i i I IN i. '_ L. I '_ I. j i I -.�. I i. �_ !.__( _ _.i _.i... ._.._..............' .�._1.... _.J....__:i. .., i ..J '._.I. ..,_S.._._t......__.�__.-_ ! - I_._...__.!__—__�..._...•. ...I I_.__I..._... : _._ I___�__... .'!—`_...I_..___1._.., ._ ! _ i _...., ! .. � .__ ' _.__ I .... I I .. ;_.__ I .,. { _ r , I 21 -- - --— I , Town of Barnstable TIME Tp� o Regulatory Services BARNSrABM Thomas F. Geiler,Director 9Q� 1639. p,Eo39�6. Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEP±IC\Disclaimer Private Septic Inspections.DOC No........ ....... Fims......o�..�...... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH f � ............ -------------------------------• Appliration for 15isposat Works Tnntrurtion Pumit Application is hereby made for a Permit to Construct (p), or Repair ( ) an Individual Sewage Disposal System at ------ -- - ---- -----= - U ..21 4oness or I.o o. aner ° dress a --------------- '........ = r Insta Address C� Q Type of Buildi Size Lot.___�rJ��.._� JSq. feet U Dwelling:No. of Bedrooms_______________._...__..____...__Expansion Attic ( 1 ) Gar�Sage Grinder ( ) 44 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures W Design Flow !�......Zallons per person per day. Total daily flow----- ' - ---------------gallons. WSeptic Tank Liquid capacity_ ___._ allons Length................ Width............---- Diameter---------------- Depth___________-_-. x Disposal Trench—No..................... Width._.____ _____ __ tal th _. .._.....__._ Total leaching area__•_._....._..:-_��_..sq. ft. Seepage Pit No.....I.............. Diameter/ .:�e� low inlet.....,.............. Total leaching area a___ __` Sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------------------------------------------------------•-------........... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pii.................... Depth to ground Water._____.____-_______.__-. G� Test Pit No. 2................minutes per inch Depth of Test Pit....-............... De 'th to ground water------------------------ a ----------------------- -- ....... ---- ------ -------•-- O Description of Soil--------------------------- �: - V ----------------------------•-----------------------------------------------------------------------------------------------•--=-•-----•-------------------------------------------------•-------------- W VNature of Repairs or Alterations—Answer when applicable----------------•------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------Agreement: I The 'undersigned agrees to install the aforedeseribed 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 r f health. � p - igned p --- -------- r Date Application Approved By---------- -------- ...----- �-- �. .. Date Application Disapproved for the following reasons:............................... ....__.______.___..___.__........._---------------•-------=------- ------- ---------•---••--•-------------------------------------------------------•-•----------------...• ----------------------------------------------------------------•------------------------------- w u Date PermitNo........................................:................. Issued........................................................ Date - r No........ FEE......;� ................. . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............OF...... Application is hereby made for a Permit to Construct (j I or Repair ( ) an Individual Sewage Disposal System at -76 ^;.......... P :: ....�•• fir' = - aW" c* f r Lot jw' r y ✓f.._. t'Y =�. ..._. .� .... .....! _ - �_ -------- ram._a_ } � W O. nor s d,, Address ----•-------- ---- - r.s ._..._. .. ... Address Type of Buildin Size Lot-----'` _.~ :_.. q. feet U Dwellin No. of Bedrooms_________________g ________________Expansion Attic (. ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ------------------------- - --------------•--• ---•-- ____ ___--------------- W Design Flow.................. .._---gallons per person per day. Total daily flow..... "' � --------:--gallons. WSeptic Tank t-Liquid capacityF/4 :4allons Length---------------- Width-------.--------- Diameter.._..------------Depth----------------- Disposal Trench—No.................... Width-_.-, .(e_eTotal n h Total leaching area.:__- ,�..sq. ft. Seepage Pit No _- *.............. Diameter/,4K-i2---� e t� lowinlet :P-_. "")� p�i _____,__ Total leaching >re�Lr. _.4.�__::`_ . ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by _-_-__._ Date.. ----------------------------------------------------- Test Pit No. 1............_--minutes per inch 'Depth of Test Pit.................... Depth to ground-'.water-__-_-----______-_-.. .. fX Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water ::------__-_____.-. i W -------- ---- .............. --- --•---. D Description of Soil-------------------------- -,, _ ....... ...' � m ------ ------- -- ----------------------- V -----------------------------------------------------------------------•------------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 �r� / _; r:signed a._¢ .F y `r -S------ .c, / r ---- ; --- f Date pplication Approved By -, �='r /1' ------------------------- ----------- A .---• -- Date Application Disapproved for the following reasons------------------------------------------- ----------------------------------------------------------- -•----..-----•---------------...........................................................-.......................................--------------------.------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date S THE COMMONWEALTH OF MASSACHUSETTS , � BOARD OE' HEALTH � 'I . ...... w rdifiratr Of TglYtphaurr , THIqy&Z TO CERTIFY, That the Individual Sewage Disposal System constructed ( r Repaired ( ) +u $ ? �le �6 ,*2t --------- - 4, r>pi ------•----------------•--------•------- Ijrta J Epp has been installed in accordance with the provi. ons of Article XI A The State Sanitary Code a describ d i the ' application for Disposal Works Construction Permit No.................... ............ da`ed. .__ ------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----------- -- .- - = ..................... Inspector----- THE COMMONWEALTH OF MASSACHUSETTS ! BOARD OE HEALTH > ! >�r A� ............................................... -IleNo...... •'�---...... FEE..2... i� >a �1 rk Cnaart # ixr$��a�t pri .. , , tPermtsston,:✓i s eby granted b � .... ---- -------------•------ ie.o Construct . . or Repair n Indt� ydualege: at No.... m -`--- .f.,.....W-�.✓- -'`'x y ` ' - -- f'--------- -- ----- ----------- ----- kE N 6 =•--•-----•aa `r - < sr tee a j as shown on the application for Dis osal Works onstruction:P a NoC = tedf =23 w11oard of health DATE .............. FORM 1255 HOBBS & WARREN. INC.. PUBLISHER$%' EXISTING SEPTIC TANK LEGEND EXISTING LEACH PIT EXISTING LEACH PIT TOP OF, TANK, EL.=96.90t N °od (PER RECORD AS-BUILT 1/12/13) (PER RECORD AS-BUILT 1112113) INV.(OUT)=95.57f - 98 -- EXISTING CONTOUR h°c ao� Bo TO BE PUMPED, FILLED WITH TO BE REMOVED-SEE NOTE 11 EXISITING LEACH PIT x 100.98 EXISTING SPOT GRADE SAND AND ABANDONED (FIELD LOCATED) PUMPED, LOCUS do c o x 92,98 O E FILLED WITH) W EXISTING WATER SERVICE o -1- 93.47 N 25'10�50�� W SAND AND ABANDONED G EXISTING GAS SERVICE z y -� -�`- OVERHEAD WIRES co c ��4 137.00 > x 97.79 TEST PIT SHED x 61 i Lo VENT �' / AB 9 -� BENCHMARK gA N 9349 98fJ4 / � � 100 i g6 - 4.21 �G x 98,0z �of1*9 TP-2 x 94,3 33.5' 'r .S 28 °Oa x 94.46� TP-1 1�'� -c-:' A 33 D S N / it 9ss ;p o � 1 R LOCUS MAP _ BENCHMARK �o O 1 ECK. NOT TO SCALE COR./CONCRETE PATIO -9 - ,,i .. _3/. K GENERAL NOTES: EL.=98.15 rr .. .,•:�9 �4 / �''•""""• 98,04 �,•"• K 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL BOARD OF HEALTH AND THE DESIGN ENGINEER. '^ N DECK 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE cnu 98.05 DECK DECK W LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: i is -310 CMR 15.405(1)(b); ' � O f 3' •`DECK=' 'mum cover requirement o , � variance nce to the maxi A 3' a a. _. 1 G C) ) i7 for up to 6' of cover over the S.A.S. o� TING 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR d M TING fen c TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE U 153 R. HO SE SIGN ENGINEER. DE RAISED RANCH Z 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING WALKOUT BASEMENT=98.2t FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN , ® , ENGINEER BEFORE CONSTRUCTION CONTINUES. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. - x / yv ' 100.14 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF 99,92 THE CO TO NOTIFY THE LOCAL BOARD OF ai CONTRACTOR OR OWNER 0 } �JOp. 100.75 + 100.49 ` HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 100,1 10�28 ° 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. o S' 100,55 �, 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. SHALL B E RES TORED AS F R FO R CONSTRUCTION 0,56 �? EA ED 10 0 AREAS CLEARED M 9. ALL A E 100.57 •x*- 100.42 "`.;•,.:::,.` � Q��� Assq� AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE 100.35 �� y O G DIRECTED BY THE APPROVING AUTHORITIES. PETER T. 100.42 g McENTEE 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY •o PP., (LO 14) o Cl T L "' THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING W \ No. 35109 CONSTRUCTION. 100.04 BL 121 -76 * .;,`...:': .','`' I �'EG/STE`��� `�� 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS `� IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND 16,250 S.F.t :100.38 100,39 \ S � REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). 100.32 ♦ 101.29 X lOL2 , ' 77 7 :L,. 40.95' 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE . _ r ! �' INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. UP < :.5:.;2 '\\10 50 E fence R -' .01.16 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND 101.94 p `'••k.:.,, �p O ® 0 +'` IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. X 100.40 99.23 99.46 edge 99,69 °f 100.30 Pavement l00•40 ° l00•41 PROPOSED SEPTIC SYSTEM UPGRADE PLAN 153 HICKORY HILL CIRCLE, OSTERVILLE, MA HICKKO R Y HILL CIRCLE Prepared for: D.A. Brown, Inc, P.O. Box 145, Centerville, MA 02632 OWNER OF RECORD Engineering by: SCALE DRAWN JOB. N0. Engineering Works Inc. 1„=20' P.T.M. 153-15 fMURPHY, RICHARD H JR ' DATE CHECKED SHEET N0. 153 HICKORY HILL ROAD 12 West Crossfield Road, Forestdole, MA 02644 OSTERVILLE, MA 02655 (508) 477-5313 5/18/15 P.T.M. 1 of 2 C r l - NOTE: TO PREVENT BREAKOUT, THE PROPOSED ` FINISH GRADE SHALL NOT BE < EL:91.0 \ FOR A DISTANCE OF 15' AROUND THE �'- SEPTIC TANK PROPOSED D—BOX PERIMETER OF THE S.A.S. . INSTALL RISERS & COVERS OVER INLET Sc INSTALL RISER & COVER PROPOSED S.A.S. \ ���5�(#1 '• OUTLET AND SET TO 6' OF FINISH GRADE VZAISED RANCH SET TO 6" OF GRADE INSTALL RISER & COVER�OVER ONE CHAMBER AND LKOUT BEMNT. 9 . T.O.S.=98.2t SET TO 3' OF F.G. TO SERVE AS INSPECTION PORT F.G. EL.=98.1 t F.G. EL.=97.6t F.G. EL.=97.6f F.G. EL.=97..6t ff CHARCOAL VENT DECK 49.9. D N 3'(max.) L = 4' L = 23' ® S=1% (MIN.) ® S=1% (MIN.) 2" LAYER OF 1/8" TO 1/2- 4 "SCH40 PVC 4"SCH40 PVC Ac DOUBLE WASHED STONE Ba as (OR APPROVED FILTER FABRIC) ' '�� 10" 8" 6aam a mm 14" as Baa EXISTING 48" LIQUID �aa�aaa ---3/4" TO 1-1/2" DOUBLE 3r, Oc�' PROP. LEVEL WASHED STONE 0000 ADD INV.=95.37 PROPOSES INV.=95.20 4' 4.8 „ 4' �� S.A.S. GAS BAFFLE D-BOX EFFECTIVE WIDTH = 12.8' N INV.=95.57t 3 OUTLETS CA` �. 33 5 63,4' EXISTING SEPTIC TANK H-10 RATED :INV.=90.50 3-500 GALLON LEACHING CHAMBERS 57.6' SURROUNDED WITH STONE AS SHOWN H-20 RATED TOP CONC. EL.=91.6 (73Hs NOTES: BREAKOUT ELEV.=91.0cri SEPTIC LAYOUT 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE INV. ELEV.=90.50 ®a®e INVERTS, PRIOR TO INSTALLATION. aaaaa aaaaa Mama aaaaa 2) D-BOX SHALL BE SET LEVEL AND TRUE TO GRADE BOTTOM ELEV.=88.50 4' 3 x 8.5'=25.5' 4' ON A MECHANICALLY COMPACTED SIX INCH CRUSHED 4' OF NATURALLY OCCURRING STONE BASE, AS SPECIFIED 310 CMR 15.221(2). PERVIOUS MATERIAL EFFECTIVE LENGTH 33.5' 3) INSTALL INLET & OUTLET TEES AS REQUIRED. 5' (MIN.) ABOVE G.W. ®E3®® 0 ®E3 E3 Ea 4) GAS BAFFLE TO BE INSTALLED ON OUTLET TEE L E6QHING SYSTEM_.SEGTION BOTTOM OF TP, EL.=82.8 = ®E E3 E3®® E3 ® ®®® 37"(H-20) AS MANUFACTURED BY TUF-TITE, ZABEL OR EQUAL. H(NO GROUNDWATER) ®®®®® ® ®�®® 33„(H-10) Z#E3 a E@E@® ® ®®®® SEPTIC SYSTEM PROFILE I - 102" SOIL LOG DESIGN CRITERIA DATE: MAY 18, 2015 (REF#14,691 4" KNOCKOUT SOIL EVALUATOR: PETER McENTEE PE(SEA42) 20" DIA. COVER NUMBER OF BEDROOMS: 4 WITNESS: DAVID STANTON R.S. HEALTH AGENT SOIL TEXTURAL CLASS: CLASS I " _ ELEV. TP-1 DEPTH I ELEV. TP—Z DEPTH 4" KNOCKOUT 4 KNOCKOUT 58" DESIGN PERCOLATION RATE: <2 MIN/IN 95.5 0111 94.3 0" (0.74 GPD/SF LOADING RATE) FILL FILL 0 I� DAILY FLOW: 440 GPD 93.2 A A 27" 92.1 26" 4" KNOCKOUT DESIGN FLOW`. 440 GPD SANDY LOAM SANDY LOAM GARBAGE GRINDER: NO—not allowed with this design 92.8 10YR 4/2 32„ 91.8 10YR 4/2 30" LEACHING AREA REQUIRED: (440 GPD) = 594.6 SF B B 500 GALLON CAPACITY SANDY LOAM SANDY LOAM.74 GPD/SF 90.5 10YR 5/6 60„ I 10YR 5/6 54" CHAMBERS EXISTING SEPTIC TANK: 1000 GALLON CAPACITY C PERC i 89.8 C PROPOSED DISTRIBUTION BOX: 1 INLET, 3 OUTLETS (H-10) 54"/72" USE 3-500 GALLON LEACHING H-20 CHAMBERS IN SERIES PROPOSED SEPTIC SYSTEM UPGRADE PLAN SURROUNDED BY DOUBLE WASHED STONE ON ALL SIDES MED. SAND i MED. SAND 153 HICKORY HILL CIRCLE, OSTERVILLE, MA SIDEWALL AREA: 2(12.8' + 33.5') X 2 = 185.2 S.F. 2.5Y 6/4 2.5Y 6/4 Prepared for: D.A. Brown, Inc, P.O. Box 145, Centerville, MA 02632 BOTTOM AREA: 12.8' x 33.5' = 428.8 S.F. II 84.0 138" 82.8 138" Engineering by: SCALE DRAWN JOB. NO. TOTAL AREA:..... . . .............................................. . ...614.0 S.F. N.T.S. P.T.M. 153-15 NO GROUNDWATER, (PERC RATE: <2 MIN./IN. Engineering Works, Inc. - DESIGN FLOW PROVIDED: 0.74 GPD/SF(614.0 SF) = 454.4 GPD 12 West Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET NO. E (508) 477-5313 5/18/15 P.T.M. 2 of 2 I