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HomeMy WebLinkAbout0154 HICKORY HILL CIRCLE - Health 154 HICKORY HILL CIRG;bSTER.VTT,I,F A=121-051 f j l , { { y v No Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplifation for 13isposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 51( 01� �"�` L�Yu� Owner's e Address and Tel No. � r✓�� V% Us�erMtikit Vw u aCo S' La`nd� �. is 4 w�k� L�,r . �1-r� oboe `i Assessor'sMap/Parcel p of 1 t sva�(0sri-S-6)Q 7 Installer's Name,Address,and Tel.No. 1 b v44t!�.q (ri, $yL,-mW 43esigner's Name,Address,and Tel.No. c�1C�� , Cam"-Tc, -77Y-3s�-co4<) 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) (J6e_e Wke-j-- d - D 4 I 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 Bo e Si e Date 7AOZId C) Application Approved by Date C�6 Application Disapproved by Date for the following reasons Permit No._��%� Date Issued No Fee �✓ ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE. MASSACHUSETTS Zipplication for,#Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair'(/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. - - �Js�:Yv,1�C � Ito 5 s" �,���``���- rs-c� �,•�Farr �,1( c AYE r a5-}��;�, � � 'Assessor's Map/Parcel ©2 1 Installer's Name,Address,and Tel.No. 1 b,,j-§f c,.V 1,1 S�,�, -4Designer'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 x Plan Date r`.. 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) a, � �. .. _L �;,, r,t, ,w c -I, 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 o Heal :' X j IA Sig.ed Date fa }' Application Approved by Date _%&4ad Application Disapproved by Date for the following reasons .-Permit No. k- Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by at ( 5 y 1{;,l�n c� t f,'r c C �5 r r�� n �a has been constructed in accordance with the provisions of Title{{5 and the for Disposal System Construction Permit Now, dated Installer 7,1;-oi �4.(t;�St'1'.i;r�.TCI.' Designer #bedrooms Approved design flow_ A' gpd The issuance of this permit shall not be construed as a guarantee that the system will fi cfion as des wed - Date :� �= fin' Inspector No.d ..� Fee _... THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS St.a Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(Z a Upgrade( ) Abandon( ) System located at I"S{/ ;t°( Ury r G,1 '< ;r�) �' r>t:a-P11V I�;a` 1'rvl ll 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:Construction must be c'mpleted within three years of the date of this pemyr Date Approved by,, ___________``� �T► ,�,ti Town of Barnstable Inspectional Services BARNWABLL 9 39. Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Thomas A.McKean,CHO FAX: 508-790-6304 CERTIFIED MAIL#7015 1730 0001 4987 7879 July 7, 2020 PINE, LINDA 154 HICKORY HILL CIRCLE OSTERVILLE, MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 154 Hickory Hill Circle, Osterville, MA was inspected on 06/11/2020 by Thomas Roux; certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR-15.00) due to the following: • The distribution box is rotted. You are ordered to replace the distribution box within one (1)year from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH 4 Zoa ncC,�RS—,"CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Conditional ly Passes Letters\154 Hickory Hill Circle Osterville.doc I �the ram, Town- of Barnstable y BARNSPABLE. b 9. ,.� Inspectional Services Department Public Health Division 200.Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface-of the ground ❑ Pumping more than'4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS Y ONE (1) YEAR DEADLINE CRITERIA. ❑ Static liquid level in the distribution box is above the outlet invert due to an overloaded or clogged SAS or cesspool ❑ A portion of the SAS, cesspool, or privy is below the high groundwater elevation ❑ A portion of the cesspool is,located within a Zone 1 to a public well ❑ A portion of the cesspool is located within 50 feet of a private water supply well ' with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR'DEADLINE CRITERIA ❑ Single Cesspool ❑ Any "conditionally passed systems" (broken cover,.relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OME Repair deadline: s ,� Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Hickory Hill Circle Property Address P 1 Linda Pine 1,5 Owner Owner's Name/ information is Osterville y Ma: 02655 June 11, 2020 required for every 'Page. City/Town 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 filling out forms 613A. Inspector Information �'�.# 114 on the computer, Thomas Roux use only the tab key to move your Name of Inspector cursor-do not use the return Company Name key. 89 Mayflower Lane Company Address East Wareham. Ma. 02538 Citylrown State Zip Code 774-678-9066 S14531 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ®� Conditionally Passes , 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspector's Signature Date c 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts (o .Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name information is Osterville Ma. 02655 June 11, 2020 required for every State Zip Code Date of Inspection page. CltylTown P P C. Inspection Summary Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 6. 1) System Passes.: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ® One or more system components as described in the"ConditionalPass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will,pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND(Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name information is required for every Osterville Ma. 02655 June 11, 2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑Y ® N ❑ ND(Explain below): The distribution box is severely corroded and is in need of replacement. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): 3) Further Evaluation is'Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9;F4 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name information is required for every Osterville Ma. 02655 June 11, 2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: []The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. [-]The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name Information is required for every Osterville Ma 02655 June 11, 2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or . tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct'the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name information is required for every Osterville Ma. 02655 June 11, 2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for aff inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? • ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form y, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name information is required for every Osterville Ma. 02655 June 11, 2020 page. Cityrrown State Zip Code Date of Inspection Do System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 395.9 gpd Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy:. current Date t5inspAoc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 _I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name information is required for every Osterville Ma. 02655 June 11 2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges.to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings;if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name information is required for every Osterville Ma. 02655 June 11, 2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 23 years, design plan dated 8/22/97. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): +10' Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5. official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a � 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name information is required for every Osterville Ma. 02655 June 11, 2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) , 6. Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: F ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) ' r If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.51 x 5.67'W x 5.67'H <1 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 32" <lit Scum thickness Distance from top'of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The septic tank does not need to be pumped out at this time. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name information is required for every Osterville Ma. 02655 June 11, 2020 page. Cityrrown State Zip Code Date of Inspection Do System Information (cont.) 7. 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.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments !y 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name information is required for every Osterville Ma. 02655 June 11, 2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The D-Box is severely corroded, and is in need of replacement. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name information is required for every Osterville Ma. 02655 June 11, 2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Since the septic tank and D-Box are both functioning correctly. Therefore,the SAS is draining properly. Type: ❑ leaching pits number: ® leaching chambers number: 8 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form I" Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .�, 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name information is required for every Osterville Ma. 02655 June 11, 2020 page. City/Town State Zip Code Date of Inspection D. System Lnformatio.n (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding; damp soil, condition of vegetation, etc.): No evidence of hydraulic failure. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name information is required for every Osterville Ma. 02655 June 11,2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name information is required for every Osterville Ma. 02655. June 11, 2020 page. C4rrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately r vwv (,,xd is N TS c O 5 �} -� eI , b-- C40/( A to S T 00+ 35, q A 46* 1 90 X � 9, 4o - goy t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name information is required for every Osterville Ma. 02655 June 11 2020 page. Cityrrown State Zip Code. . Date of Inspection D. System Information (coot.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ' ® Shallow wells below 10' 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: 8/22/97 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: You must describe how you established the high ground water elevation: From the design plan on file. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts t� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 154 Hickory Hill Circle Property Address Linda Pine Owner Owner's Name information is required for every Osterville Ma. 02655 June 11, 2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and.1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form - Not.for.Voluntary Assessments . 154 Hickory Hill'Circle Property Address Ann Hubby Owner Owner's Name information is required for Ostervllle -MA 02655 -`-- -February 14,2012..__. every page. City/Town State Zip Code Date of Inspection - Inspection results must be submitted on this form. Inspection forms may not be altered in any - _- way: Please seecompleteness checklist at the end of the form. Important: A. General.Information When filling out forms on the `i t computer,use 1. Inspector: only the tab key p to move your Patrick M. O'Connell _ cursor-do not use the return Name of Inspector key. Septic Inspection Services Co. Company Name raD 189 Cammett.Road Company Address Marstons Mills MA 02648, City/Town State .; Zip Code 508-428-1779 SI 12855 Telephone Number License Number _ � • �� Cer.#ification- -.____.---__._._- - -- __.._.;_. �_ -__ _ _ , ..:... ._ _ _ .�� ._.,. I certify that] have We 6rially'inspected the-sewage disposa.[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: w.� ® Passes ❑ Conditionally Passes ❑ rFails " ❑ Needs Further valuation by the Local Approving Authority •� `-, February 14, 20 12 Job# 12-21 Inspector's Signature. Date The system inspector shall submit a copy`of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days.of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER 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 V v Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage,Disposal System Form - Not for Voluntary Assessments w., 154 Hickory Hill Circle Property Address Ann Hubby Owner Owner's Name information is Osterville MA 02655 February 14, 2012 required for — 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: Tank was not in need of pumping at time of inspection, leaching system had no standing-water or evidence of surcharge. B) System Conditionally Passes: FT One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes'',"no" or"not determined" (Y, N, ND) for the following statements..If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration-or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a.Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 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 154 Hickory Hill Circle Property Address Ann Hubby Owner Owner's Name information is Osterville MA 02655 February"14, 2012 required for every page. City/Town 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 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).- El The system required pumping more than 4 times a year due to.broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which,require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System 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 Page 3 of 17 t5ins•11/10 . Title 5 official Inspection Form:Subsurface Sewage Disposal System s � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 154 Hickory Hill Circle Property Address Ann Hubby Owner Owner's Name information is Osterville MA 02655 February 14 2012 required for every page. CitylTown State 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 Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and.the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS.and the SAS.is less than 100 feet but 50 feet or more from a private water supply well**: Method used to determine distance.- This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 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 clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded El ® or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than._day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 : \ Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 154 Hickory Hill Circles Property Address Ann Hubby Owner Owner's Name information is Osterville MA 02655 February 14, 2012 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more.than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ElAny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private.water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply Elthe system is located in a nitrogen sensitive area(Interim Wellhead Protection El Area- IWPA) or a mapped Zone li 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_ t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 154 Hickory Hill Circle Property Address Ann Hubby Owner Owner's Name information is Osterville MA 02655 February 14, 2012 required for State Zip Code Date of Inspection every page. City/Town C. Checklist Check if the following have been done.You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not ® ❑ available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the.SAS,located on site? ® ❑ Were the septic tank manholes uncovered,,opened, and the interior of the tank . inspected for the condition of"the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue. approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 3. 3 Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 t5ins•11110 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 154 Hickory Hill Circle Property Address Ann Hubby Owner Owner's Name information is osterville MA 02655 February 14, 2012 required for State Zip Code Date of Inspection every page. Cityfrown D. System Information Description: 0 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? El yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No 2 Months prior to Last date of occupancy: inspection. . Commercial/industrial How 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: i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts = Title 5 official Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments 154 Hickory Hill Circle Property Address Ann Hubby Owner Owner's Name information is required for Osteryille MA 02655 February 14, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Tank pumped in 2010 Source of information: 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, distribution box,soil absorption system Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if'yesi 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 11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page B of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form - Not for Voluntary'Assessments 154 Hickory Hill Circle Property Address Ann Hubby Owner Owner's Name information is required for Cisterville MA 02655 February 14 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1998 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate.on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): _ 8" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal', list age: . years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 10.5' long x 5.8'wide- 1500 gal. Dimensions: 01. Sludge depth: t5ins•11I10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary,Assessments w� 154 Hickory Hill Circle Property Address Ann Hubby Owner Owner's Name information is Cisterville MA 02655 February 14 2012 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet.tee or,baffle o„ 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 Measured 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.): Tank.had liquid only, no solids. Liquid level was found at bottom of outlet invert and tees were intact. 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 t5ins•11110 Title 5 official Inspection Form:Subsurface Sewage bisposal System•Page 10 of 17 - Commonwealth of Massachusetts s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for,Voluntary Assessments 154 Hickory Hill Circle Property Address Ann Hubby Owner Owner's Name information is Osterville MA 02655 February 14 2012 required for every page. CitylTown 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.): at ti me of inspection) locate on site Ian): Holding Tank tank must be pumped p ) ( P Tight or Ho p � P 9 9 Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition.of alarm and float switches, etc.): Attach copy of current,Pumping contract (required). Is copy.attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w„ 154 Hickory Hill Circle Property Address Ann Hubby Owner Owner's Name information is Osterville MA 02655 February 14, 2012 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan):. 0.1 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.): No solids or high stains present Pump Chamber(locat e on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Page 12 of 17 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System• . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form. Not for Voluntary Assessments 154 Hickory Hill Circle Property Address Ann Hubby Owner Owner's Name information is Clsterville MA 02655 February 14, 2012 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont:) Type: ❑ . leaching pits number: .8 Infiltrators. ®. 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.): Interior of infiltrators were video inspected with no standing water or evidence of surcharge found. 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 l5ins•11/10 Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 t Commonwealth of Massachusetts Title 5- Official Inspection . Form Subsurface Sewage Disposal System Form Not for Voluntary.Assessments 154 Hickory Hill Circle Property Address Ann Hubby Owner Owner's Name information is osterville MA 02655 February 14 2012 required for State Zip Code Date of Inspection every page. City/Town 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 of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Title 5 Official inspection form:Subsurface Sewage Disposal System•Page 14 of 17 t5ins•11/10 - I . I Commonwealth of Massachusetts - Title 5 Official Inspection form Subsurface Sewage Disposal System Form Not for Voluntary Assessments o 154 Hickory Hill Circle -.— Property Address --- — --- Ann Hubby = --= --- -- -- -- ----- -- _ ---- Owner Owner's Name information is Osterville MA 02655 February 14, 2012_ required for -- -- --- ' every page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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 33 16 Back Yard r, Commonwealth of Massachusetts Title 5 Official Ins ection Form p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 154 Hickory Hill Circle Property Address Ann Hubby Owner Owner's Name information is required for Osterville MA 02655 February 14, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ®. Check cellar ® Shallow wells 20+ 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 8/22/97 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: You must describe how you established the high groundwater elevation: Perc test performed on 6/20/97 found no water at 10 feet. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System Page 16 of 17 i Commonwealth of Massachusetts s Title 5 Official Inspection Form a� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 154 Hickory Hill Circle Property Address Ann Hubby Owner Owner's Name information is required for Osterville MA 02655 February 14, 2012 every page. City/Town 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 ® System Information— Estimated depth to high groundwater. ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11110 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 17 of 17 } TOWN OF BA/RNSTABLE LOCATION )J� 'Gotr� /r'1/S L:r SEWAGE # va:I:AGE 051`trvf ASSESSOR'S MAP & LOT 0-2/- 05 INSTALLER'S NAME&PHONE NO. Tv4 ti 14 e. I7'a SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUII,DER R OWNER lSo SG✓ e�+ h PERMTTDATE: 9- /I- 2 COMPLIANCE DATE: _�� ^ k — Separation Distance Between the: 1 Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland.and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r s 3 0 � y 3 z86�' 21 3. 4 � � l�l No. Fee —0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZIPPrtcation fo 'Mi.5pont *pgtem Construction Permit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. i , o�� ,+ Owner's Name,Address and Tel.No. Assessor's Map/Parcel r Q © 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations er when(Answer applicable) ,y SAS. H 7e-e e C�GLG o% 4.t 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 an not to place the system in operation until a Certifi- cate of Compliance has been issued by t ' o/If Healt Signed Date 2—/� 98 Application Approved by Date Application Disapproved for the following reasons Permit No. v Date Issued f! C w THE COMMONWEALTH OF MASSACHUSETTS--, Entered in computer:. PUBLIC HEALTH DIVISION —TOWN OF BARNSTABLES MASSACHUSETTS Yes 6131 Rpplication fo Dtgpoial 60tem Couttruction Virimit Application for a Permit to Construct( Repair(, .)Upgrade( )Abandon( ) O Complete System ❑Individual-Components Location Address or Lot No. 0/ /� Owner's Name,Address and Tel.No. Assessor's'Map/Parcel '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 gallons per day. Calculated daily flow «/ gallons. Plan Date Number of sheets Revision Date i Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs orAlterati)n's(Answer when applicable) t.} �t9 4/F I I s q S, 4 y_� r2�t/G ofg*y,e 4i�C /y y A+47 7ie e J ; Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance wi.h the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by th' o=dfalth ,� - '• Signed Date Date Application Approved by Date Application Disapproved for the following reasons ry Permit No.,/ Date Issued — ———————————————————————————— ——————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Se}�age Disposal System Constructed Repaired ( )Upgraded( ) Abandoned( )by T at �/ r r vt l� has be n constructed in accordance With the provisions of Title 5 an the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date_ C/ Inspector ql?7 —— ———————————————————————————— 1 ~ THE COMMONWEALTH OF MASSACHUSETTS �4 PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS, =i0po.5ar pgtem Construction Permit Permission is hereby granted to Construct( Repair( )Upgrade( )Abandon System located at /S'! /f 4•, �� Ci,r �� � �u/(v ��S��//�v C2 s e-, and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: Approved by�l�1 ti � Town of Barnstable P# 9 3 9' Department of Health,Safety,and Environmental Services Public Health Division Date 367 Main Street,Hyannis MA 02601 S HAWWAWX MM9. fo ►�� Date Scheduled !S -Z­ `!7 Time /a Fee Pd.— 1119e, Soil Suitability Assessment for Sewage Disposal Performed By: r Witnessed By: ,Te r7-y LYCATION GENERAL INFORMATION Loc n-Add. sus /c•)CO"Pi- ii 6Z <,AZ66 Owner's Name Address Ll5,-etv%_//C'- Assessor's Map/Parcel: / //�� Engineer's Name %ua.i �f�c•✓% NEW CONSTRUCTION V REPAIR Telephone#w,�-- � 711 - V S Land Use auInool ew Slopes(%)a--3 7r Surface Stones Distances from: Open Water Body Taft Possible Wet Area �/� ft Drinking Water Well ft Drainage Way N/f4 ft Property Line ft Other L 0 M/1) ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) S! S¢ 1• � yr ID ss� r Qy '9 )VIGIIOAr-r 4/,1LL G i 1Z CLC Parent material(geologic) 9i7*r.is sLl Flo/'� Depth to Bedrock Depth to Groundwater: Standing Water in Hole: .v/!- Weeping from Pit Face 11V/A 5to /w4Gu , Estimated Seasonal High Groundwater .5b-c3.0 30"A /JPr- G rr,�Ne/wet7`et- Crn,7bur r�,,,aRETL121VIINATION VOR SEASONAL 11169. Vt�ATEIt'TABLE Method Used: 1k)QX. q14 o `ry r -ir,ctP Depth Obse ed standing in obs.hole: N/A" in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: VJ41 in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ PERCOLATION TEST vate j ;Tlmc � . Observation Hole#oZ Time at 9" Depth of Perc 60 Time at 6" Start Pre-soak Time cQ Time(9"-6'1 End Pre-soak x Rate Min./Inch Lo't/bJ/J�i�— Site Suitability Assessment: Site Passed V-1— Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back---� Copy: Applicant .. DEEP OBSERVATION ROLE LOG` Hole# _ her Depth from Soil Horizon Soil Texture Soil Color Soil Structure`Stones,Boulderes. Surface(in.) (USDA) (Munsell) g o arriGS/Brae 3 � o .Y► ��✓ 3 4-a b 640 /o Y b/Y� P6-6( C e'l — r�iy Yt l7/lee loose 1-0O CoZ o I DEEP OBSERVATION HOLE LOG` Hole#$ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % O — nic:s ,�trrr ty y e 6-33 a�✓ loa.4, any✓ o DEEP'OBSERVATION`RO�E LOG Ilole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling StructuConsistena—re,Stones,Boulderes. 0 . n DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % DEEP.OBSERVATION DOLE LOG Vole Depth from Soil Horizon 111 Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stricture,Stones,Boulderes. on I Lot 52 f Lot 53 - _ ' .. _.. ab Off v,'V - -- --- 4z:0 ,3M44.1 TN4 3olT V y, 30' r, • �, Hickory � J.� ! 1Saa t�ncPOSPD $ill h qsr ha o a H circle' :d:es'ign. ` M , Lot 51 a - . r�, -_ e... o. bedrooms 3 }_. -- --- -- ' o leachlin o: soa 49 Req.. g 3'30 q 'd eq.' GST 1500 gal , J 40 ' �de Disposal j no t . Provided i15x25=375;xi. 74= 277 ;5! , _w ! • ' � , . � - ._180-x2- 1-60�•:�7,4----1-18:- 5 1 i t iv o 12 N E + f TO,tdl leaching :395 .9� :gpd Lot �5 4 i 15050 sf. `•io.7 • i 133.48 f i i . . . 4(s•I { ! j Lot 55 '. se iI _i . .: 1 _ _• x 1 j . . . i �o--8 high c�apac•ity nfiltra' as: s ofi`-wn.wi Fi, 3►-of sfon- ` om ends ;anal middle. _ . .1 j . t of11e no s le `r s ca 1 4' VC > �'n1Y. jot 14- r ,. .. .'(�, //•I1/I _: a ' '�_[_,';•A TTOh— f ts — - f �ww•±..-�'QIS� r`.-�'•^J-s.v^<w,«,++...w r:wcs.'i. .a a. �..' .,;e w .,.,L�;, �4ry�. .- -.n.� ... - - y"Y-"'�.--'• .. - •'4---'�'w.i .r�}� -'y_ .' �..-.''ice'` _ '.k•+:.�x.'-'.+�c5i...ay f-roi�' _•. 3" I r • rsY+� 39.s f , - - - --- 2. Infi t I , 5 8 1 rat�ors : . 1 . . . . . 1. U <+ iU p G U ci » �+GCi V c,;; G GJ 0.) t C�6>g4 GU ! . w f � ..�_.. ._...._ ., i �..�, ....,•n t - �... ». _ ,. .. ...a. , - ,. _ a y- s _ I 1 I � 1�1 1 1� Site Plan of Land 'in OstervIlle, MA �SNOF For. Sweeney Construction ;0 Being lot 54 as shown on 'a plan 're: o E. Map 121 pcl 051 corded in book 199 page 3'1. i�. Te t pit P-8939 Elevations are on NGVD Made 5-20-97 i �'AsTEP � Wit. J. Dunning ; i s�avAL ' ! ? No water encountered Date: Agent; Barnstable board -of hea'lth ' Perc. less. 21 min per .1n = - ' ale 1"- Date T- P4�5 T P 2 gSry .. Cape ;Engineering 1 Sc 30 ' 8 22 97 s h`s 491Harbor: Road - ` ! sN•+� ;l�P Hyannis, MA 02601 j 0 Co4Q_5e 4 1 >t , j r C 1 t ooz �1 , I �•ry�ryf Q , L