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Home My WebLink About0273 HICKORY HILL CIRCLE - Health 273 Hickory bill Circle Osterville A= 1.20-010 0 u �.``� Zd'.A- ��r 273 Hickory Hill Circle Osterville A= 1.20-010 I i i M EA® No.2-153LGW UPC 12134 smead.com • Made in USA f" 5� �n No. 5 mil/V�� Fee y a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftphLation for Misposar *pstem Cunstru>rtiun permit Application for a Permit to Construct( ) Repair( Upgrade(✓Abandon( ) ❑Complete System Individual Components Location Address or Lot No. ?��lClCOf2l`//�/L4 G/ze wrler's Name,Address,and Tel.No. 0.5 Assessor's Map,'ParcW 1` —/Q ALL Installer's Name Ad ess,an Tel.No.SN9.,9_7a JV.2, Designer's Name,Address,and Tel.No. ti'El. . C17 _457 16 B.�i�sov l+✓ ozw,m �' > Ra a 12myrs 7 Type of Building: Dwelling No.of Bedrooms 1 Lot Size sq.ft. Garbage Grinder(^� Other Type of Building Z No.of Persons Showers( ) Cafeteria(/j Other FixturesLl Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date D - JDA Title 51 a I`" 6 a,1VA6,6 F_4 9-yr/ T,,��' ,h�x /9/iW -I(-A c A/,4- ✓4xk T I Size of Septic Tank / OMP S Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) rDiFz E / S t Lt: !L Gov P 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 e the system in operation until a Certificate of Compliance has been issued by this Boar f He 1,29 Si ed Date � Application Approved by — Date /p� (�s Application Disapproved by Date for the following reasons Permit No. (� _ Date Issued 41. No. /✓ /33 - Fee THE COMMONWEALTH�OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for -Misposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(,- U rade Abandon( ) ❑Complete System Individual Components Location Address or Lot No. �� r-l" wner's Name,Address,and Tel.No. 0.5 c� 21011/«g a2 Assessor's Map/ParcW —/O /YK&d& Installer's Name Address,and Tel.No.Sd 9,2 7, - Designer's Name,Address'and Tel.No. fkk/ Tg d/zizE t 11J oiv lz t ,m -r- )v tp L s / �' - /,77 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 r7r"` 1 gpd Plan Date Number of sheets Revision Date / Title S/ r-- S�(/� J�� 1,{�/ S)� ��k f i�F/r - FG�f^;/ i/4f,- Size of Septic Tank,/, 0156 !f' .Type of S.A.S. Description of Soil'\, Nature of Repairs or Alterations(Answer whe applicable) + L �U : - �/� S^ r 5 'LG i iX i rya Date last inspected: � - Agreement: ' r 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 the system in operation until a Certificate of .F Compliance has been issued by this Boar Me Si ed Date 9 9 Application Approved by Date G� Application Disapproved by Date for the following reasons Permit No. /'j 3 Date Issued -------------------------------------------------------------------------------------------------`---------------------------------- THE COMMONWEALTH OF MASSACHUSETTS 4, ��, n BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded Abandoned( )by / �[�/C o at � fL has been constructed in accordance with the provisions of Title 5 and the r Disposal System Construction Permit No 3 33dated J h Installer Z. Designer /r19-&RSAe�l_ le S' #bedrooms Approved desig flow t 3.3 y gpd The issuance of t i�^permitAall not be construed as a guarantee that thAystem wil \nct o /as design d. Date IU �j P Ins ector (f -- ---------------------------- 3 3 No. �j Fee T THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal 6pstrm Construction 3permit Permission is hereby granted to Construct( L) Repair( ) Upgrade(/ Abandon( ) System located at � 7 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 b complet d within three years of the date of this permit. Date C�/'//3� t77 �� Approved b Commonwealth of Massachusetts 00 - 070 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 273 Hickory Hill Road Property Address i David Cook Owner Owner's Name information is required for every Osterville page. City/Town Ma. 02655 10/08/2015 .� State Zip Code Date of Inspection N3 PP L� 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 211// on the computer, 514 ! use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Inspector Name of Ins key. P Cape Septic Inspections Q Company Name 624 Old Barnstable Road Company Address Mashpee Ma 02649 Cltyrrown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 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 10/09/2015 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 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page oY f 17 Commonwealt h of Massachusetts - Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -•`' 273 Hickory Hill Road Property Address David Cook Owner information is Owner's Name required for every Osterville Ma. 02655 10/08/2015 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: This home has a H-10 1000 gallon septic tank a H-10 D-Box and two pre-cast leaching pits B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 3 t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17 1_ Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 273 Hickory Hill Road Property Address David Cook Owner Owner's Name information is required for every Osterville Ma. 02655 10/08/2015 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): T ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): 1 ❑ 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): t 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 273 Hickory Hill Road Property Address David Cook Owner Owner's Name f information is required for every Osterville Ma. 02655 10/08/2015 page. City/Town 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 99 p ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I_ Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °y 273 Hickory Hill Road Property Address David Cook Owner Owner's Name information is required for every Ostervllle Ma. 02655 10/08/2015 page. Cityrrown 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. ❑ ® 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. ❑ ® 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 ❑ ❑ 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 L Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 273 Hickory Hill Road Property Address David Cook Owner Owner's Name information is OSterville required for every Ma. 02655 10/08/2015 page. City/Town State Zip Code* Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as 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: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based,on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >440 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 273 Hickory Hill Road Property Address David Cook Owner Owner's Name information is required for every Osterville Ma. 02655 10/08/2015 page. City/Town State Zip Code Date of Inspection D. System Information Description: . F Number of current residents: 5 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: I called the water dept. at 2;37 pm they were too occupied to give the reading at the monent. 15 .D Sump pump? ❑ Yes ® No Last date of occupancy: occupied until 10/7/2015 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: t5ins-3113 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 273 Hickory Hill Road Property Address David Cook Owner Owner's Name information is required for every Osterville Ma. 02655 10/08/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Peter Debarrows Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: Apx. 1000 gallons gallons How was quantity pumped determined? Drivers est. Reason for pumping: Install new D=Box 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 273 Hickory Hill Road Property Address David Cook Owner Owner's Name information is required for every Osterville Ma. 02655 10/08/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1983 plans from Barnstable Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 23" 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): 14" 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 Dimensions: standard 1000 gallon 3" Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 1 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 273 Hickory Hill Road Property Address David Cook Owner Owner's Name information is required for every Osterville Ma. 02655 10/08/2015 page. Cltyrrown 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 apx. 35" 1 Scum thickness Distance from top of scum to top of outlet tee or baffle apx. 5" Distance from bottom of scum to bottom of outlet tee or baffle apx. 12" How were dimensions determined? sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The H-10 septic tank was pumped as part of the inspection.I would recommend the new owner put the tank on a maint. plan with a local septic pumping co. based on the future use of the home.The Barnstable Health Dept. has a list of local pumping co. + I, Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete. ❑ metal ❑ fiberglass ❑ polyethylene El 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 p Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 273 Hickory Hill Road Property Address David Cook Owner Owner's Name information is required for every Osterville Ma. 02655 10/08/2015 page. Cityrrown 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 pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 1 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 273 Hickory Hill Road Property Address David Cook Owner Owner's Name information is required for every Osterville Ma. 02655 10/08/2015 page. City/Town 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 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.): A new D-Box was installed as part of the inspection Speed levels were also installed 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form R o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 273 Hickory Hill Road Property Address David Cook Owner Owner's Name information is required for every Osterville Ma. 02655 10/08/2015 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: Two ❑ leaching chambers number: ❑ leachinggalleries number: 9 , ❑ 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.): There are two leaching pits fed by a D-Box with adjustable flow Ievelers.One of the leaching pit has been full in the past the other has a stain line apx. 1/3 up the sidewall of the pit. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert F. Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 A Commonwealth of Massachusetts _ Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 273 Hickory Hill Road Property Address David Cook Owner Owner's Name information is required for every Osterville Ma. 02655 10/08/2015 page. Cityr town 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 of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Ins pection Form A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 273 Hickory Hill Road Property Address David Cook Owner Owner's Name information is required for every Osterville Ma. 02655 10/08/2015 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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 C� V r I L . 3 _ N41 3Z ' 2 � !S- 3 39 , 6- Y = 3, C- Y = 30 ' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M •�° 273 Hickory Hill Road Property Address David Cook Owner Owner's Name information is required for every Osterville Ma. 02655 10/08/2015 page. Citylrown 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: 15plus feet 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: You must describe how you established the high ground water elevation: I augered a hole to 15 feet. Before filing this Inspection Report, please see Report Completeness Checklist on next page.` t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 273 Hickory Hill Road Property Address David Cook Owner Owner's Name information is required for every Osterville Ma. 02655 10/08/2015 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 ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file �r • �T'SJ M d{' S. �• S. t P)U5 FeeT i N j z ® o -T t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1 yrd CrILf� 4 Town`of Barnstable Department of Regulatory Services p . t�AB,Epc Public Health Division Date ' ` /g 's 200 Main Street,Hyannis MA 02601 ,.. Date Scheduled ��► 5' Time Fee Pd. SoIlSuitl-fityAs ssment or Sewa a Dis osal.f p��,gy��p® P gp Performed By: Witnessed By::'sQ�"'�fi' LOCATION&GENERAL INFORMATION Location Address Owner's NameVLA Address (.1 �.. Assessor's Map/Parcel: '`�/"1 � � Engineer's Name � �T • NEW CONSTRUCTION REPAIR Telephone#'EaO c�C Land Use Slopes(%) Surface Stones - Distances from: Open Water Body ft `Possible Wet Area ft Drinking Water Well ,p. ft Drainage Way - ft Property Line ft. Other SKETCH:(Street name,dhnensions act locations of test holes&perc tests,locate wetlands in proximity to holes) Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in.' Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST Date Time Observation Hole# _ Time at 9" Depth of Perc Time at 6" , Start Pre-soak Time @ Zp Time(9"-V) End Pre-soak �Jf Rate MmAnch Site Suitability Assessment: Site Pass Site Failed: Additional Testing Needed(Y/N) '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 Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC I • � YYJJJ r N� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders. if Consistenc %Gravel V — .. 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) 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) 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) r Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year boundary No �6e1_ Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pery a rial exist in all areas observed throughout the area proposed for the soil absorption system? tp� , If not,what is the depth f na , lly occurring pervi us material? P Certification' I certify that on 6 Q (date)I have passed the soil evaluator examination approved by the Department of Enviro enta Protection and that the a ove analysis was perfo ed by'me consistent with the required traitting,expertise an xperie crib X:te 15.017. Signature �2-DlL--7 Q:\SEPTIC)PERCFORM.DOC . Commonwealth of Massachusetts C — Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 273 Hickory Hill Circle Property Address Beverly Whitney Owner Owner's Name information is required for every Osterville MA 02655 September 13, 2010 ' 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 A. General Information - on the computer, use only the tab 1. Inspector: V key to move your cursor-do not t David D. Coughanowr use the return Name of Inspector key. Eco-Tech Environmental Company Name 43 Triangle Circle ` Company Address Sandwich MA 02563 City/Town State Zip Code 508 364 0894 1328 Telephone Number License Number B. Certification u M 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a 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 September 13, 2010 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 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•091138 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts. -_ -= � Title 5 :Official Inspection Form s Subsurface Sewage Disposal.System Form - Not,for Voluntary-Assessments w,,—,.• 273.Hickory Hill Circle Property Address Beverly Whitney: Owner Owner's Name_ information is required for every Osterville MA 02655 September 13, 2010 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day itwas inspected. No estimate or-guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described.in the "Conditional Pass"section need to be replaced..or repaired. The.system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or determined" (Y, N. ND)for the following statements. If"not determined;".please explain. The septic tank is metal and overr20 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•09108 Title 5.official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 , Commonwealth of Massachusetts a Title 5 Official Inspection Form • Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 273 Hickory Hill Circle Property Address Beverly Whitney Owner Owner's Name information is required for every Osterville MA 02655 September 13, 2010 page. Cityfrown 'State . Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out 6r 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 ❑ Yr ❑ N ❑ ND(Explain below): The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed k❑ 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 x 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 t ❑ 'Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09M Tille 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts FTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 273 Hickory Hill Circle Property Address Beverly Whitney Owner Owner's Name information is Osterville MA 02655 September 13, 2010 required for every _— P page. Cityrrown 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 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 or clogged SAS or cesspool - El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow 15ins-09l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts 7 l ug Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 273 Hickory Hill Circle Property Address Beverly Whitney Owner Owner's Name information is required for every Osterville MA 02655 September 13, 2010 page. Citylrown 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). Nurnber of times pumped:- El ® 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. ❑ ® 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 16,000 gpd. For large systems, you must indicate either"yes or"no"to each of the following, in addition to the` questions in Section D. . Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system.is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area=IWPA)or a mapped Zone 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. t5ins•09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17' i Commonwealth of Massachusetts - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 273 Hickory Hill Circle Property Address Beverly Whitney Owner Owner's Name information is required for every Osterville MA 02655 September 13, 2010 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 ® ❑ 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: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd t5ins•09= Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 273 Hickory Hill Circle Property Address Beverly Whitney Owner Owner's Name information is required for every Osterville MA 02655 September,13, 2010 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 360 gpd Detail: 2008-2009 (Irrigation system in place).. Sump pump? ❑ Yes Z No Last date of occupancy: i May, 2010 Date 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: l5ins•09= 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 273 Hickory Hill Circle Property Address Beverly Whitney Owner Owner's Name information is Osterville MA 02655 September 13, 2010 required for every _P page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below):, General Information Pumping Records: 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 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'f 273 Hickory Hill Circle Property Address Beverly Whitney Owner Owner's Name information is Osterville MA 02655 September 13, required for every 2010 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Age 26+ years. Certificate of Compliance issued 12/16/83 (Board of Health permit#83-910) Were sewage odors detected when arriving at the site? ❑ Yes'® No Building Sewer(locate on site plan): Depth below grade: 2 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.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate.on site plan): Depth below grade: • 1 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 8.5ftx5ftx5ft(1000gal) Dimensions: Sludge depth: 4 in t5ins-09108 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 a " Commonwealth of Massachusetts Title 5 Official Inspection Form x Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 273 Hickory Hill Circle Property Address Beverly Whitney Owner Owner's Name information is. required for every osterville MA 02655 September 13, 2010 page. Cityfrown State Zip Code Date of Inspection D. System Information .(cont.) Septic Tank (cost:) Distance from top of sludge.to bottom of outlet tee or baffle 30 in Scum thickness 0 in Distance from top of scum to top of outlet tee or baffle 10'in Distance from.bottom.of scum to bottom of outlet tee or baffle 14 in Now were dimensions determined.? Design plan Comments (on pumping recommendations,, inlet and outlet tee or baffle.condition, structural integrity; liquid levels:as related to outlet invert;evidence of leakage;etc.): Pumping is not required:af this timec but maintenance pumping is recommended within and every two years.Tank appears structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: R 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 l5ins•09108r Title.5 6iricial Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts: Title 5 Official Inspection Form -_ — Subsurface Sewage Disposal System Form- Not for Voluntary Assessments. 273 Hickory Hill Circle i �4aY Property Address Beverly Whitney Owner Owner's Name- , information i e Osterville MA' 02655 Se tember 13, 20'1b required for very p page. City/Town State Zip Code Date 'of Inspection D. System Information (conf) Comments (on pumping recommendations, i Net:and outlet tee or baffle condition;,,structural integrity, liquid levels as related to outlet invert, eVidence of leakage, etc:): a Tight or Holding Tank (tank must b er pumped.at time bf inspection)(locate on sife plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑-other(explain): Dimensions: Capacity: gallons Design Flow: gallons per'day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in.working order: ❑' Yes ❑. No. Date,of last;pumping' Date' Comments (condition of alarm and'float switches;, etc:): Attach copy of current pumping contract(required). is copy attached'? ❑ Yes ❑ No i5ins;09108 'LUo 5 Dificial InspeeiionEorm:Subsurlace Sewage Disposal Sysiem Page,ftof:1I Commonwealth of Massachusetts l� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y� 273 Hickory Hill Circle Property Address Beverly-Whitney Owner Owners Name' required fn is Osterville MA 02655 September 13, 2010 required for every. p page. cityrrown 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 at outlet inverts 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.): Distribution box appears structurally sound. A bucket of water was poured in and was observed to pass through in a rapid and unobstructed manner. Distribution appears.even. 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.): Soil Absorption System($AS) (locate on site,plan; excavation not required.): If SAS not located, explain why: t5ins•09108 Title 5 Official Inspeclion Form!Subsu�aco'Sewage DiSposaf System-Page 12 of°17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 273 Hickory Hill Circle Property Address Beverly Whitney Owner Owners Name information is required for every OSterville MA 02655 September 13, 2010 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): Soils above leaching pits appear unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down into leach pits. 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 15ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 or 17' 'Commonwealth of Massachusetts Title 5 Official Inspection Farm. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w.._ 2.73 Hickory Hill Circle Property Address Beverly Whitney Owner owner's Name information is required for every Ostery.ill.e MA. 02655 September 13, 2010 page. Cityrrown' State Zip Code Date of Inspection D.. System Information (cony.)' Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, :etc.): Privy(locate on site plan); Materials of constr'uction --- Dimensions _Depth of.solids Comments (note condition of soil,,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins 09f0,8, Title 5 O(faal Inspection Form:.Subsurface Sewage Disposal System•Rage 14 of 17 i Commonwealth of Massachusetts' -, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 273 Hickory Hill Circle M Ll" Property Address BeverlyWhitney Owner Owner's Name T information is Osterville MA 02655 Se tember 13, 2010 required for every p Ci Frown page. �Y 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 bores"below: Z hand-sketch in the area below ❑ drawing attached,separately { C 1 17 4 �^ 3 753 Ft 2� F- •� -X P i .. 0 t '.,Fj__ 2-7 S W t5ins•09168 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 15,of 1.7 Commonwealth of Massachusetts - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 273 Hickory Hill Circle Property Address Beverly Whitney Owner Owner's Name information is required for every Osteryille MA 02655 September 13, 2010 page. citylrown 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: 40 ft 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: 10/21/83 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: USGS Topography maps You must describe how you established the high ground water elevation: No groundwater was observed to a depth of 4.3 feet below the elevation of the bottom of the SAS in a witnessed test pit on 4/16/81. USGS Topography maps indicate property is 40 feet above the groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 6 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, 273 Hickory Hill Circle Property Address Beverly Whitney Owner Owner's Name information is required for every Osterville MA 'O 655 September 1.3,r 2016 page. City/Town state: 'Zip.Code Date ofanspection 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 growndvvater' Sketch of Sewage.Dispo,sal .Sym ste ;either&awn on page 1.5 orattached in separate file) t5ins_-09108. T111e 5 Ofriciarinspeclion Form.Subsurfacb Sowaflo Disposal;System;-Page.17.of 17, l ' LOCATION SEWAGE PERMIT NO. VILLAGE INSTALL R'S NAME & ADDRESS B UILDE R. OR OWNER ® ATE PERMIT ISSUED DAT E C 0 M P L I A N C E ISSUED &4E ''�� V\ � � �,� �► � � � � . � � .� c�� - T� T • w �. No.. �. 1.. Fes$...... __._.`.... THE COMMONWEALTH OF MASSACHUSETTS v ' _ BOARD OF HEALTH I2,0-01 .a.S .. .............OF.......Iv. .- •-1•. .Q.Iert.................................. Appliration for Mipaiial Njark,5 Cron.6trnrtion Frrmit Application is hereby made for a Permit to Construct (a/�or Repair ( ) an Individual Sewage Disposal System at: .........Kdl ...!�k2 I .... L!5 ...... 3....................................................•... ly catio dress or Lot No. e !�.Q...... .t .....�` ... ..•9-mac .T�.................................................... O n Address a ..........�..._.....�. .�: �. .1:�.................. Installer Address U Type of Building Size Lot.... .Sq. feet Dwelling—No. of Bedrooms--------- ( ) Garbage (AJ4_____________________________Expansion Attic Garba e Gander 1114 Other—Type of Building ..... No. of persons._.__.!;?�:................. Showers (,'1_) — Cafeteria Wd R, Other fixtures -----••••--••---•--------------• _... W Design Flow.......:.....sS.S.......................gallons per person per day. Total daily flow----------3_AQ.....................gallons. 1:4 Septic Tank—Liquid capacity.!1-0.01.C°gallons Length---l_d_....... Width.....lt....... Diameter...__10........ Depth................ Disposal Trench—No. .....W4-57. Width.................... Total Length.................... Total leaching area...► IA.....sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box (� Dosing t ( Se�� j��,,e(r,��--, , - / ►-+ y 2efX C Evt He��..... ate F ,! a Percolation Test Results Performed b -._ . ...._...._ )� ...:......... . .1A �-. ;�P._.. .._... .— a Test Pit No. 1__4_�.minutes per inch Depth o Test Pit _____ _______ Depth to ground water_._1�-�_.___.._ -..-_. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water................_______- ..................f•....................--- O Description of Soil..•---0- -. ......I�?,Pw"!_....*... .f------•----- - ----------•--•------------------••••-----•----•-._....-••-_--_.. x -_.. 1- j w►• ±�2�°........--'-=... ---------------------------------------------------------------- W -------•----•-------=-----•-•-------...•---•--...---•---•..__......._._.._.__.-.._..•••......-----------••-•-••---------=---•---•---•-••••-•-•--------•--•-•--•-•------•----•-•-----------...--•---•---- t` V 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 iITL 11 5 of the State Sanitary Code_=The undersigtie�d'further agrees not to place the system in r operation until a Certificate of Compliance has been issued by the of health. Sined- �---••------------------- l g .._ ,�......... ....... /.��__.._ _ ate Application Approved By..... ••--._.._._. ......_.. ..---4 /� X, Date Application Disapproved f r the following reasons:----••--------•-••--•---•------•----•-------•-----•-•--•---------------------------------- ................................••-•-•-•--••-•-•-----•-•---._..........----.............. ..................•--•-•---•----•---------------------------•-•-----••-----•---••---...------ ..__..._...._ Date PermitNo......................................................... Issued-........................................................ Date , w No.. .3.--.------... YEF.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ►. ......._..OF.......t Ct;Z.1u `(�.✓ .►=.- _...---................................ Appliratilan for Diipniittl Varkii Tontrurtion rrmff Application is hereby made for a Permit to Construct (1_�Or Repair ( ) an Individual Sewage Disposal System at:t f+ l --.� 1 1._`.. .1r4.... ..--• -•--.....0.:......... ...... ........--' -- ................................................ rLocatio Address or Lot No. ......................^ te... f yF) i �.�..:1 !? t✓iC (_ - ,U �. .................. ............."................_..._.` a:.......................................................... Owner r� _Address Installer Address dType of Building Size Lot....!.-a t`a- ____Sq. feet U Dwelling—No. of Bedrooms...........: .............................Expansion Attic (kP Garbage Grinder (Al)' Other—Type of Buildii:.g ..... No. of persons___..-!;;�:................. Showers ( 2L) — Cafeteria (,Uej QI Other fixtures .................................. W Design Flow............. ._.....................gallons per person per day. Total daily flow.___.__...-�-�•---------._.______._gallons. WSeptic Tank—Liquid capacity... gallons Length---1_0....... Width.....6....... Diameter..._4......_. Depth................ x Disposal Trench—No. .... __. Width.................... Total Length.................... Total leaching area....5.12.....sq. ft. Seepage Pit No.-_____-__-- ...... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (L.,-� Dosing tank ( ) 5 e( tx�x c( a Percolation Test Results Performed by.... "/�/<<{.t r _�... J.t_ t .r.�s:. �1df ate............. ...... ..- Test Pit No. 1__K.:?=_.r-linutes per inch Depth of-Test Pit.................... Depth to ground water.._ l....!_::..: G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... a ..............................................=............................................................................................................... Description of Soil ---------- - ......----- - -----------'�1, t c r c r.4-� r l7 t v l y S e s e,t c .......................•.. •------••---.............._.. y W ---- -------- ......----............................................................................................................................................................................... UNature of Repairs or Alterations—Answer when applicable.__............................................................................................. ---------------------------------'----------------------------------------------------------.......--------•-•--------------------------------••------------------------------------------------•--•-•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL: 5 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. qy ! ( � ic Lw r y / Signed._ `j`� ` ?� 'r .�.. /1��.. ._... 'y Date Application Approved By.--- :� Date Application Disapproved for the following reasons:------•--------'---------------'----'----------------------....'•---------------'.....-----"--'-------........ --------------•------------•-----'--------------------------.......-•--••-•----------....................._..._................._.....------•---•----------------------•-----•-•-•------------•••....... Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF.......c:%'t....��;P, .�, 11,E f't'...................................... (9rdifiratr of Toutplittnrr / THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (sue) or Repaired ( ) by............. �.1...6 re �Vic" t I ................•----------.....------------------'----------'•-------•-•------•--'---------........._...-•----.....---•-'------•-••--.........•--- ' j // / j� Installer at............ •--�/f�/ 1 T =�1./-/ ,� ^/ f i/�'_/r_... ="= { ! -------------------------------'----'-----..._.....-.----- has been installed in accordance with the provisions of TIT I3F�' S �The State Sanitary Co a esx>bed in the application for Disposal Works Construction Permit No.._r7."'"__...................... datedr __�-.___.._........._........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WI FOCTION SATISFACTORY. DATE..;ZY/.._�?-./.--4.3.....-------•---•---•------------------------------- Inspector--- .... ...................'..................................................... d _ r E THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c/ 1 ........... .F � ?'-i.. ......................... L N ..__.._.... FEE........................ �i��ro��t1 ork� �on�#rnr�ion rruti# Permission is hereby granted......._l.=-_.... A ...'116... to Construct ( i,�oor Repair ( ) at! Individual Sewage Disposal System at No. 3 f..... 1. r--........... /t�� (..f�'..-...........'----•-----------•----•------•-------• ......... 61 Street as shown on the application for Disposal Works Construction Permit No._ _: _..... Dated.......................................... ..........Z17� DATE............... �Q Z Board of Health ......-------•----------------------- FORM 1255 A. M. SULKIN, INC., BOSTON - r _00- 7 2- cV� tY 4 S-9 t t o ( r N Y �1 ➢ 1} i 2 N 07 z, V�3 x �o MORSIE w 10951 O GIST av�iv�i v. FSSIONA\-.1 LEGEND OF ° CERTIFIED PLOT PLAN EXISTING SPOT ELEVATION Ox0 �N Mgss EXISTING CONTOUR--- p --- .��' ROe�RT . yG Via? 3 /-1 FINISHED SPOT ELEVATION BRUCE '„ FINISHED CONTOUR Q "' k.._ `<E�QR APPROVED , BOARD OF HEALTH o a �' � ,IN $* DATE AGENT s a : .�. y r';' SCALE1A / "=3 0 ' DATE, 9 3 v �S 3 LORE06E ENGINEERING CO. 13�4ysr0E. �N ChI,ENT I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED ,�O$ Nt,.y '3 2-F7 ,. BMILDING .SHOWN ON THIS PLAN CIVIL LAND' .CONFORMS TO THE ZONING LAWS E GINEER RV DRrBY' OF BARNSTABLE, MAS ON. BY iJ } 712 MAIN STREET .' �' iE HYANNIS, MASS. SHET.:_f D T REG. LAND SURVEYOR' ZO FT. I'//M. •lO.TE E.�I C.N/NG P/T A AZr MORE, THAN 9 !2"� EL:�ry e. /O PT. M/A/. TFR • COJVGRET 9'oYC P/PC .SJrALL BE BROUGNT TD GRAOE.lyE.4Vy C^ ST 'RON GJY ? b G 2. COYEJ�S MI�1/. P/TCM E.4 h�f3 L f 3f 1 /F/.Y VE,•vA Y a M/N E /O o 6.44L. s •. o eel C.- -s/a r ;'f0 PrfR/T. S�PT/C ��/�// O/ST. • dpI s .• . • •• • s •a• &A 5 HFO S7`=A,ejp . - .. _ - - . .__ - . BOX • t • • r � • • • • • ► �•• •. i• .t ' 1 r •EFFECT/YL • ' �� :«,'•% ' • • • e�o �•• �' 0 � � WASHED STJ,y� ,-70 /J pir Sz/8 cPo • • e r • s • .� • r s' • • • 78 . X /,o _ 7B i es • .® . • e •• • o ; PRECAST SE.Gp,4GE dJVto�i 7 ,eA4 6�AT/a44I� 7�7�x: c4M.�c i%'y - 109� �fnD` • a cu • -?AfYZR7'All BGVLD�N� :t�o.o �L PT'S R� 37 t3Y E�•T� , s •G L 5+3 vT C , . - Fr.. : �&.PT G/�tJM. ,,� -' -•. . '' Ottrt T 'PT/C?' �s.• _ tt_ JWT O.G4J►f. Ga�SEt►7--J4 L.:I T101iI} INK 9�• �_ _ ONTl!'I�t.9TRFBtlTl0l�t 6 SErCTIQJ�`Q/tt- GROt/KO JtpQTE*V Ti 04Ar > ZVLA&t Aq CWI W *Vs, WAOMIA � f'- . DIMMNJ/OJV -AIL 01AFAXS/ON j 6' a�.�NNI/8E/P OF�OsrS�04rpS 3 - ' •.. z. -<, C%A-9& a.rp/S,p05AL LW/T /VII"— m�o/L` LOG - w/Mewsiaw ;C 4 ja „� -':r07-44 E.?T1AS47Eo lc W pV 3 3 y G.4L./44 v S O/L TEST o/ 5®!L TFST,�tg y T SO/.L TE1 T NUNfBFR GF 4eACditNG SIDE LG'AC-MI V6 PFJt O/T � pT. •--._... TEST a`9GTTOM t,tcs��K/NG oL�R P!T 7 F� SO. JtT. L` LO Via$ JtFSIILTS h%ITN�'SSEO dY C7�1 �a2�✓�ryracxer < _i_SQ-- F T. . 0T.'�C LEaCN/If�G �aREA S Z- St .3 SG i L :�ESERYE LEACtl1X6 ARE N 53Z SQ. FT. , !�E - p scoc.�e r/0.4 A-47'k f 2 7P w . '1/x /NCAl sir OF P✓ •6 OF Mass' 11 T ROBERT G BRUCE .� //o ALBERT ;oyG ! ✓STD l q E,LDRE a, I L ! 1 es v SE. No.10951 O EL.OREDGE t Nv/NE1��T%/ti G CO�I.YG f S T 7/ wfA J � `�k� %L`G f). 2 //Y S T. ., '/ `.> H SLR C Na GTONNJ fYAr-e#v fNGOCJNTE.4�O E- 6;Y�Sl'fh IEel-AFM �C] GM O uN0 N.AEI 7- � AtiT=c ca i t1 � V! ASSESSORS MAP : JEST I- 0LOGS -a PARCEL : TC�j� I L C S _ 1) 'I he installation shall comj:, %villa •Title V and •I'own of*,m t)oard of FLOOD ZONE: SOIL EVALUATOR :(DI-t')/D e 0�6 1 lealth R ,egulalions. WITNESS : , 2) I lie installer shall verily (lie location of utilities sewer invcr(s and septic REFERENCE: '�E,� �# 25�zd , DATE: cS Z5' Q/ components prior to installation and setting! base eleva(ions. 4)(, C PERCOLAT I O1J RATE: -` !1�/ 3) All gravity septic piping to be 4 inch Sch ,I(I 1,VC al 1/8,, per loot. 'I 1 Ii rst err Y• ��, two leet out of the d-box to the ieaching stall be level. i /�1�� ! _ V __ 4) 'I his plan is not to be utilized for property line determination nor any other RSV - -- -- TH- I TH 2 purpose other than the proposed system installation. A 0 ru) Aol�DaaC7/�o 5) All septic components must meet 'fitle V specifications. - 6) larking shall not be constructed over I110 septic components. n. _ ) property Y property property ' t� 7 'I lieis bounded b corners and lines. 8) 'fhe property owner shall review design considerations to approve of total LOCATION MAP _ design d es flow and member of bedrooms to be considered for clesi t n. IZeceit i 3 6 g of payment for the plan and installation based on the plan shall be deemed approval of(he design (low by the owner. ILI V V lip 9) I he existing leaching or cesspools shall be pumped and tilled with material per title V abandonment procedures. 'I'hose within the proposed SAS shall be removed along with contaminated soil and replaced wills clean sand per � 00 f b Title V specs. �� 10)System coiii poi ertts to be 10 flee (roin water line. Sewer !roes crossing the water line shall be sleeved with 4 inch SCI140 PVC with ends grouted if applicable. •1 he proposed SAS is being installed below the water service `S 8 -7,;r-zG,So Ca line. "I'he line is to be sleeved as aforemendoned and maintained in place. SEPTIC SYSTEM DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the a��2 " owner to ensure such. l FLOW ESTIMATE 12)'I he installer is to take caution in excavation around the gas line if such exists. �. I � 3 BEDROOMS AT ID GAL/DAY/BEDROOM - GAL/DAY 13)"I tie installer shall verily the location, quanlity and elevation of the sewer - \ � V lines exitin+, the dwelling prior to the installation. SEPTIC IA14K 14)'1 his plan is representative only that a system can lit on a property meeting \ � I •�!! �I � 'I itle V requirements. GAL/DAY x 2 DAYS - GAL 40 k6p USE WO GALLON SEPTIC TANK EMIT040 tnllt 4 -3--- m - �� SOIL AB.ORPTION SYSTEM 1 40 3, �2tvt ir!!4 11 U i (> ��7MVgr �Y�ut40. Akt OFA�,gS., 4 `t~ ,4 n sF _ - _ S t`�E AREA• Z� Z�J-h IZ�g�j )( Z 1 II,q 7 DAVIT] s9� o y M� O , / I 1 BOTTOM AREA: 2 �( 1 Qc1. - �J7��j MASON `��I _0 o +► 1 M �o No 1066 3 SEPT I C SYSTEM SECTION . 53 D a 1•yam' G� F � ,n w. � 4 d9 ILJ �t� - - ---__ Q lOb�2 GAL � tL1(f�9� 'D� '� o SEPTIC TANK 3 t 0 4-6 �p �,to", \ SITE AND SEWAGE P LAN - � AZ I YoR I I LOCAT 10N : 73 G \ �L L &L& 0myl LUG S� qw- 0 -2,0o PREPARED FOR : _ -DAVlP GTZK Z0 DAV I D B . MASON RS DATE: ZrA DBC ENVIRONMENTAL DESIGNS DATE HEALTH AGENT EAST SANDWICH . MA _ ---- ( 508 ) 833- 2 177