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Commonwealth of Massachusetts I�d`
Title 5 Official Inspection Four'
Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments
i
10 Hollingsworth rd
Property Address hw�
Mary Ann McCartin _... T.
Owner
Owner's Name
information is �
required for every Osteryille ✓ Ma 02655 6/30/17
page. City/Town State Zip Code Date of Inspection _-
0
Inspection results must be submitted on this form. Inspection forms may not be altered in any.
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael DiBuono
use the return Name of Inspector
key.
DiBuono Sewer and Drain
,a Company Name
35 Content Ln
Company Address
Cotuit MA 02635
City/Town State Zip Code
508-364-9587 S113522
Telephone Number License Number
B. Certification.
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. 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
7/5/16
In'spector'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
M 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 1 of 17
- a
Commonwealth of'Massachusetts
W Title 5 Official Inspection Forte
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Hollingsworth rd
Property Address
Mary Ann McCartin
Owner Owner's Name
information is required for every Osterville Ma 02655 6/30/17
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:
® 1 have-not found any information which indicates that any;of the,failure criteria described
in'310 CMR 15.303-o� in 3'10 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below. .
Comments:
Sytem contains a 1500 Gallon septic tank. As well as a concrete distribution box and a leach field
with infultrators 10'x40'x2'
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):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 10 Hollingsworth rd
Property Address _
Mary Ann McCartin
Owner Owner's Name "
information is required for every Osterville Ma 02655 6/30/17
page. City[Town 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):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System 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: a. .
❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Hollingsworth rd
Property Address
Mary Ann McCartin
Owner Owner's Name
information is required for every Osterville Ma 02655 6130/17
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
❑ ® 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 '/z day flow
t5ins•311 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of'Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Hollingsworth rd
Property Address _
Mary Ann McCartin
Owner Owner's Name
information is Osterville Ma 02655 6/30/17
required for every� '
page. CityrFown 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 wit hin+100 feet of a surface water supply or
E N 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.
❑ ® An portion of a cesspool or privy is less than 100 feet but greater than 50 feet
YP P p Y
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 mast 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
El. El Area=1WPA)or a mapped Zone Hof 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
l
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Hollingsworth rd
Property Address
Mary Ann McCartin
Owner Owner's Name
information is required for every Osteryille. Ma 02655 6/30/17
page. CityFrown 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?
® El 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 .
h
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Hollingsworth rd
Property Address
Mary Ann McCartin
Owner Owner's Name
information is required for every Osterville Ma 02655 6/30/17
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Vacant
Number of current residents:
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 ears usage 228 GPD
( Y 9 (gpd))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 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:
•
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Hollingsworth rd `
Property Address
- Mary Ann McCartin
Owner Owner's Name
information is required for every Osterville Ma 02655 6/30/17
page. CitylTown 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: Unknow
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
P p
y
❑ 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
i
. Commonwealth of Massachusetts
0.1 Title 5 Official inspection Form
Subsurface Sewage Disposal System Foram -.Not for Voluntary Assessments
10 Hollingsworth rd
Property Address _
Mary Ann McCartin
Owner Owner's Name
information is Osterville Ma 02655 6/30/17 required for every '
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:
17 Years
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.):
System is vented at the roof line
Septic Tank (locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500
If tank is metal list age:
years
is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments
10 Hollingsworth rd
Property Address
Mary Ann McCartin
Owner Owner's Name
information is required for every Osterville Ma 02655 6/30/17
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top o,'sludge to bottom.of outlet tee or baffle
24"
Scum thickness Y
Distance from top of scum to top of outlet tee or baffle
42"
Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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•3/13 Title 5 official tnspeotion Form:Subsurface Sewage Disposal System•Page 10 of 17
J
Y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foram - Not for Voluntary Assessments
10 Hollingsworth rd
Property.Address
Mary Ann McCartin
Owner Owner's Name
information is required for every. Oste'rville Ma 02655 6/30/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be 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 .
Commonwealth of Massachusetts
:. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments
10 Hollingsworth rd .
Property Address
LL Mary Ann McCartin
Owner Owners Name
information is
required for every Osterville Ma 02655 6/30/17
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 Level with no signs of higher levels than
normal
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* 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•3113 Title 5 Official Inspection Fqrm:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 10 Hollingsworth rd
Property Address
Mary Ann McCartin
Owner Owner's Name
information is Osterville Ma 02655 6/30/17
required for every "
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number:
Infultrators
❑ 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.):
No ponding no breakout
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Hollingsworth rd -
Property Address
Mary Ann McCartin
Owner Owners Name
information is
required for every Osterville Ma 02655 6/30/17
page. City/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.):
t
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:SYbsurface Sewage Disposal System•Page 14 of 17
f
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 10 Hollingsworth rd
Property Address
Mary Ann McCartili
Owner Owner's Name -
information is Osterville Ma 02655 6/30/17 .
required for every '
page. City/Town 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 .
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
a ,
Commonwealth of Massachusetts
W `title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 Hollingsworth rd
Property Address
Mary Ann McCartin
Owner Owners Name
information is
required for every Osterville Ma 02655 6/30/17
page. City/Town 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: 10+
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:
Test hole data on plan
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
7/5/20.17 Assessing As-Built Cards
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LOCATION WA V1!%5 taJ cl- �.Rep SEWAGE ii q 4) �f�1/��y
VILLAGE ASSESSOR'S MAP&LOThw �/ r�—
INSTALLER'S NAME&PHONE NO. _.l CA v ct 4,�
SEPTIC TANK CAPACITY l5 Cc �F}t_.
D
LEACHING FACILITY:(type) (size)/t7'X Yv�K.k,
j NO. BEDROODiS
BUII,D OROWNFR-i-E-6p Rut Wcil
PERMITDATE: Wra,
COMPLIANCE DATE: D
Separation Distance Between the:
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 Teaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Fumished by
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http://www.townofbarnstable.usiAssessing/HMdisplay,asp?mappar=140072001&geq=1 112
Commonwealth of.Massachusetts
„-- W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 10 Hollingsworth rd
Property Address
Mary Ann McCartin
Owner Owner's Name
information is required for every Osteryille Ma 02655 6/30/17
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
t5i s•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17.of 17
i
j"ET°�ti Town of Barnstable
Regulatory Services
DARNSfABM p'
0 39.r�•• -
Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
August 8,2017
Mr. Mark McCartin
10 Hollingsworth Road
Osterville, MA 02655
RE: 10 Hollingsworth Road, Osterville
Map & Parcel 140-072-001
Dear Mr. McCartin:
This is to acknowledge that based on the septic permit# 99-592 and on the
Baxter Nye Engineering & Surveying letter dated August 4, 2017, the
septic system at 10 Hollingsworth Road, Map & Parcel 140-072-001, is
designed for four(4)bedrooms and qualifies as a four (4)bedroom home.
Sincerely,
WITIMean R.S., C O
Director of Public Health
Town of Barnstable,
Q:\WPFILES\10 Hollingsworth Rd Ost McCartin.docx
a
BAXTER NYE ENGINEERING & SURVEYING
Registered Professional Engineers and Land Surveyors
78 North Street,3Td Floor,Hyannis,MA 02601 Tel: (508)771-7502 Fax: (508)771-7622
August 4,2017
Ms. Donna Miorandi
Barnstable Health Dept.
200 Main St.
Hyannis, MA 02655 -
RE: 10 Hollingsworth Rd.,Osterville, MA
Title 5—Existing System Capacity Analysis
Dear Ms.Miorandi:
At the request of the McCartin's,please accept this letter as a verification of the calculated septic system capacity for
the existing Title 5 septic system located at 10 Hollingsworth Rd in Osterville. Please note this letter only addresses the
supported design flow based on the below Noted Documents. This letter is not intended to address any other septic
system items such as the condition of the system,existing setbacks,current overlay conditions or siting location..
Documents used to perform this calculation are as follows(the Noted Documents):
1. Septic Permit#99-592 dated 9/10/1999.
2. Septic As-built card#99-592 dated 3/7/2000. -
The above septic as-built card notes the installed system as a 1,500 gallon septic tank and a soil absorption system
(SAS)consisting of infiltrators and stone sized at 10 ft wide x 40 ft long x 2 ft depth. As there is no perc test data
available on this system we have assumed a Class I soil with a perc rate<5 min/in. This is based on experience in the
area and other perc test information performed on Hollingsworth Rd.in the vicinity of this address'.
Based on the above noted sizing of the SAS and the assumed perc rate,this system would support a design flow of 444
gpd. Each bedroom is required to have a flow of 110 gpd/bedroom. Based on this information the system can support
a four(4) bedroom design flow which would be 440 gpd.
Additionally,it is noted,we pulled the existing Building Permit application#42394 for this property,dated 11/15/1999,
and this permit notes the construction of a "new 4 bedroom home". This application references under the Health
Division section the septic permit#99-592.
I trust this provides the-information you-requested. Please contact me with any questions you may have.
Very truly yours,
Baxter Nye EngineeringKSurveyin N OF Mgss�o
moo`' MATTHEW tN
W.
o EDDY -�
CIVIL cn
atthew E dy,P.E. No.43183
Managing Partner
FG/STF-
Cc: Mr. Mark McCartin FSS/ONAL
File
0:\2013\2013-060\ADMIN\LETTERS\McCartin-10 Hollingsworth septic.docx
Land Surveying • Site Design • Subdivisions • Septic Design • Wetland Filings • Planning d„
r
TOWN OF BARNSTABLE .oG�
LOCATION X a3 t L^ -d V1, ZJ— SEWAGE# 19
VILLAGE p✓ ASSESSOR'S MAP & LOT/4® -Wl
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 1 n A A'{ CSA!E,5, (size) ft)I X, eto 14 a
NO. OF BEDROOMS
BIJILDE OR OWNER RUt (dCG,
PERMITDATE: O COMPLIANCE DATE: ,31 U 0
Separation Distance Between the:
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
79 '
3
33
l /
:i 1 v Fee /
No..s
THE COMMONWEALTH OF MASS[ CHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zppfication for ligpoml bpztem Construction Vertnit
Application for a Pemut to Construct( * )Repair(K Upgrade( )Abandon( ) O Complete System O Individual Components
Location Address or Lot No. fa/ / //�//�-C' � wner's Name,Address and Tel.No.
Assessor's Map/Parcel / O ST6le. /1 ,/�/ln pj yy�j
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
00 AAI�rO A
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 Rep ' o teration hiLer wh app 'cable
s
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 Certifi-
cate of Compliance has been issued thi Board of Health.
Signed Date a y
Application Approved by Date
Application Disapproved for the following reasons
00
Permit No. Date Issued
No'�, (/ Fee
Entered in computer:
THE COMMONWEALTH. MASSACHUSETTS Yes
- PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIpprication for Migpogal *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair(K"TJpgrade( )Abandon( ) ❑Complete System E)IndivtdQ.'&; lSo ents
Location Address or Lot No. / �/ 1 /A// C�>>)yt� ner's Name,Address and Tel.No.'It rr
Assessor's Ma /Parcel / 0(�JC•y�6l" J WI/ / p �)�
p V �497 Z— I �V1�: pv
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�JOO A&�VO
Type of Building: j
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.n
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
.Description of Soil
r'
f
'Nature of Repaks or terations n r wh applicable `✓O 0
"""Date last inspected:
Agreement:
The undersigned agrees to ensure`the construction and maintenance of the afore described on sitesewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi=
Cate of Chip ante has been issueT Xhisoard of Health.
4 Signed Date 9 r7{
Application-Approved by =` Date 9
Appl cation Disapproved for the following reasons I
on
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that th O -site Sewage Disposal System Constructed( )Repaired ( )Upgraded( )
Abandoned by
at % h0�e_d
nstructed in accordance
with the provisions of Title 5 and the for Disposal System Cons tion Permit No. —'"
Installer >. Designer
The issuance of this perm�th 1 of be construed as a guarantee that th sy e ill u o as sig a k`�
Date Inspector
I,I I I __ —0-
_.---.-- -- ----- —------------------ --- ---
_._ _. _ ..
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS '
f
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
miqogaf *pgte Congtr rtton Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( )
System located at
,..a- 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 t t e
Date: Approved by
a� w ,
L -�7
1i6i99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERIIIT (WITHOUT DESIGNED PLANS)
I, hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at meets all of the
following criteria-
• The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the
t madmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimotor
method when applicable]
• If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14) feet above the maximum adjusted
goundwater table ele,iation.
Please complete the following:
rrn
A) Top of Ground Surface Elevation(using GIS information)
✓ 1
B) G.W. Elevation +the�fAX. High G.W. Adjustment .O_
DIFFERENCE BETWEEN A and B r
SIGNED : DATE:
[Sketch proposed plan of system on back].
q:health,folder:cent
i ro TOWN OF BARNSTABLE y
LOCATION H0 LWye S t1J 61 iAN `Zin SEWAGE # cl 9
VILLAGE (�iS�-. ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /5 00 6b'-L.
LEACHING FACILITY: (type) D
(size)
} NO. F BEDROOMS
BUII.D OR OWNER aS b Out
Ut ( dr-
i
PERMTTDATE: 101qq
COMPLIANCE DATE: Q
j Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility
j PP Y g (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
i
i
tJ,,i
'I
i
TOWN-;OF BARNSTABLE BUILDING PERMIT APPLICATION
l T �'' �n"�1, fiPermit# /4 2 �
Map Parcel F�jj. I;� S' STlEhl 110�7 � tU
INSTALLED IN COPAPLIA -,� �
Health Division _� - A-5?a V�aflT#I TI• L Date Issued 11 -d 5 .�
Conservation Division fI Cl � v �, e A Fee, _5 �2 16"f
Tax Collector y y .: (,•
Treasurer
Planning Dept. - \
Date Definitive-P n Approved by Planning Board U
Historic=OKH `
Preservation/Hyannis u
Hari,;
Project Street Address A
Village 467Ltvlr tc
Owner I� i L 1/1r eei2T1�1 Addressd�Ci�t%�Swaor�s�°
Telephone Q5'�`;'
Permit Request
Square feet: 1st floor: existing proposed. 2nd floor: existing proposed 4;;;0e Total new
Estimated Project Cost '( ' Zoning District Flood Plain Groundwater Overlay
Construction Type_ 00
�Ps33
Lot Size lTy& - Grandfathered: es ❑ No If yes, attach supporting documentation..
Dwelling Type: Single Family Two Family ❑- Multi-Family(#units)
Age of Existing Structures Historic House: 0 Yes ANo On Old King's Highway: ❑Yes kNo
Basement Type: P F9 ❑Crawl . ❑Walkout ❑Other
Basement Finished Area(sq.ft.) 62 Basement Unfinished Area(sq.ft) �aa
Number of Baths: Full: existing new Half:existing new
Number of Bedrooms: existing new _
Total Room Count(not including baths): existing -new-7 first Floor Room Count
r Heat Type and Fuel: as ❑Oil ❑ Electric ❑Other
Central Air: es ❑No Fireplaces: Existing New / Existing wood/coal stove: O Yes N0
Detached garage:❑existing ❑new size Pool:0 existing ❑new size Barn:0 existing ❑new size.
Attached garage:❑existing ew size QVXIY Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded
Commercial ❑Yes ❑No If yes, site plan review# {
Current Use Proposed Use
BUILDER INFORMATION
Name Telephone Number ��6
Address �� ` �' License#
e25Z&-&4Z-& 1144 �� _Home Improvement Contractor# %l -3 5, !2
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO-
SIGNATURE YE 1 �1 DATE /
SM®di- DETECTORS C.
BARNSTABLE BUILDING Dif..
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--�- A4.1
Page 1 of 4
�^
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49 ray i n J, Ti V�
I�U
Lodged In As: a rce I Deta i I Thursday, December 20 2007
Parcel Lookup
Parcel Info
Parcel ID E140-072-001 Developer .LOT 1A
Lot° ...
Location; ._-__,. , ..._.
10 HO
LLINGSWORTH ROAD Pri Frontage '150
E._...._.._. ............. ................. ............ ............. ................ ............... .....: ................ ............... ...,,._.. .............:. ........ ..._..,......... ......
Sec
Sec Road !WIANNO AVENUE Frontage 165
Village;OSTERVILLE Fire District C-O-MM
Sewer Acct; Road Index 0726
Interactive r,
Map {
Owner Info
owner MCCARTIN, PHILIP C & Co-owner
Streetl ,10 HOLLINGSWORTH RD Street2
City OSTERVILLE State MA Zip ,02655 Country USA
Land Info
Acres F6.45 use Single Fam MDL 01 Zoning R& Nghbd i0112
_.._
Topography Level Road Paved
....... _.._._.. . ........... ._....... ................... .......... .. ......._..
utilities;Public Water,Gas,Septic Location
file://C:\DOCUME—l\mlorandd\LOCALS-1\Temp\7QITBLJY.htm 12/20/2007
Page 2 of 4
Construction Info
Building
Year E Roof .......... Ext ... ..
Built`2000 struct Gable/Hip wall,Wood Shingle
Effect,,_ _ Roof AC
3222 Asph/F GIs/Cmp (Central �I BM7F
Area ` Cover.. Type
s
style.Cape Cod In Plastered Bed 4 Bedrooms
wall Rooms
Model;Residential Int 1 Bath 12 Full + 1 H a
Floor 1 Rooms B p♦,((;� ££ I ♦♦�, t1A)l
Heat Total'•._.,, _ .,.,
Grade. CUStOm Hot Air [E8 Rooms
Type Rooms 7 FqR
E Heat """"'� _ Found-,
Stories<1 1/2 Stones Gas
Fuel ation
Permit History
Issue Date Purpose Permit# ,amount Insp Date Comments
11/15/1999 New Dwelling 42394 $168,400 5/2/2000 12:00:00 DEMO PERMIT
AM INCLUDED
Visit History . ...,.,, _............... _ _ ..:..,_..,
Date Who Purpose ;
4/23/2007 12:00:00 AM Paul Talbot Cyclical Inspection
4/9/2007 12:00:00 AM Karen Perry In Office Review
7/31/2003 12:00:00 AM Paul Talbot Meas/Est `
4/19/2001 12:00:00 AM Paul Talbot Meas/Listed
2/7/2001 12:00:00 AM Martin Flynn Meas/Listed
5/2/2000 12:00:00 AM Martin Flynn Drive by inspection only
Sales History .. ...
Line Sale Date Owner Book/Page Sale Price
1 MCCARTIN, PHILIP C & MARY ANN 1395/291 $0
file://C:\DOCUME—I\miorandd\LOCALS—I\Temp\7QITBLJY.htm 12/20/2007
Page 3 of 4
i'
_._...Assessment History
Save## Year Building Valve XF Value OB Value Land Value Total Parcel Value
1 2007 $431,500 $2,900 $7,300 $371,800 $813,500
2 2006 $389,900 $2,900 $7,500 $270,400 $670,700
3 2005 $359,000 $3,000 $7,700 $248,800 $618,500
4 2004 $303,400 $3,000 $7,800 $248,800 $563,000
5 2003 $292,000 $3,000 $8,000 $388,400 $691,400
6 2002 $324,000 $3,000 $10,000 $408,800 $745,800
7 2001 $0 $0 $24,300 $408,800 $433,100
8 2000 $51,400 $2,000 $12,500 $144,900 $210,800
9 1999 $51,400 $2,000 $10,000 $144,900 - $208,300
10 1998 $51,400 $2,000 $10,000 $144,900 $208,300
11 1997 $45,300 .$0 $0 $144,900 $194,900
12 1996 $45,300 $0 $0 $144,900 $194,900
13 1995 $45,300 J. . $0 $0 $144,900 $194,900
14 1994 $49,300 $0 $0 $130,400 $185,100
15 1993 $49,300 $0 $0 $130,400 $185,100
16 1992 $56,200 $0 $0 $144,900 $207,200
17 1991 $69,000 $0 $0 $217,400 $301,400
Photos
file://C:\DOCUME-1\miorandd\LOCALS-1\Temp\7Q 1 TBLJY.htm 12/20/2007
Page 4 of 4
i yaFe p,
mar .�� 46Eax n
file://C:\DOCUME-1\miorandd\LOCALS-1\Temp\7Q 1 TBLJY.htm 12/20/2007
TOWN„OF BARNSTABLE BUILDING PERMIT APPLICATION
Map. Parcel — F-� � TIC 'STEM t,� � Permit#
ar e" S c r a b r
o wjU ,
JF INST .LL ��� t® Ilif Lfx�f
Health Division 9E1- Sri'1 DL N. � � a TC0 Date Issued I 1 —� S`- C) C)
Conservation Division / ` , �� Feed .5�-5Z:O
Tax Collector 1 .c . L��. �t 1
Treasurer
'- .
Planning Dept.
. Date Definitive P n A proved by Planning Board
iK
Historic-OKH\-�\ Preservation/Hyannis �i�
l
Project Street Address ,4&,CGS 1
Village . 4'ZW VI L
Owner i f, /�-L�� 2T1iV AddressD�GHSa,��y
Telephone2�s
Permit Request
Square feet: 1st floor: existing _ proposed 2nd floor: existing proposed 5W Total new S DD
Estimated Project Cost '' ;J ,— Zoning District flood Plain Groundwater Overlay
Construction Type Aloo �ofh::,-
Lot SizeTif6 - Grandfathered: es ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family D"" Two Family ❑ Multi-Family(#units)
Age of Existing Structure /t&-ZA/ Historic House: ❑Yes ANo On Old King's Highway: ❑Yes XNo
Basement Type: PFlu ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) 62 Basement Unfinished Area(sq.ft) dd�
Number of Baths: Full: existing new Half:existing new
Number of Bedrooms: existing new _5
Total Room Count(not including baths): existing new—7 First Floor Room Count ,
-Heat-Type and Fuel: as ❑Oil ❑Electric ❑Other
Central Air: 4v es ❑No Fireplaces: Existing New . Existing wood/coal stove: ❑Yes N0
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ew size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
BUILDER INFORMATION
/�Lf �l-
Name f1�o�ivjC-� Telephone Number 46
Address P License#
45 -� Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
DATE
SIGNATURE �• ZI
JACOB LILLEY
ARCHITECTS,INC.
103 CENTRAL STREET
WELLESLEY,MA 02482 C
T:781.431.6100
q
—————————————————— - 1
SCOPE OF WORK I ..
I
I
MASTER CLOSET I MASTER BAT I - -
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d W
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u /
II p W'Di
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MASTER BR(BEDROOM#I)
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REMOVE DOOR AND RELOCATE NEW DOOR w I -
...
---------=-------
LL o` I
d I
Lill,
.TRYFOYER N FAMILVR UPSEAL:
� DEMO WALL AND REMOVE THE DOOR I` I/ �, DEMO EXISTING TILES• -L---------------J - o.I "uaRDDM )- we ESLEY I I I E9.1 3° A oW
SCOPE OF WORK. . P`y.
ON
--_ — — I I r
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E HISTORY:.
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SET
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LIVING4
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NO. 03.16
- DATE 08.03.18
'SCALE 1/4"=r-O"
BY - JL
s -
s i I
E32 ( PARTITION SCHEDULE EXISTING
FIRST FLOOR I
TO BE REMOVED y Fff
1
1 FIRST FLOOR PLAN
11'41!V-O" PROPOSED WALLS i
"
EX1 .1
,
,ate-- � .�•-� �... —�-�=�- _ {�
JACOB LILLEY
ARCHITECTS,INC.
103 CENTRAL STREET
WELLESLEY,MA 02482
T:781.431.6100
COLLAR TIE
EXISTING STAIRS(BEYOND(
W
1 E7.7 7v
W
SECTION AT GARAGE LOFT V
1 -
LU
BEOROOMa2 1�
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1
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7
>D.,U. _— --JLEY,A CE(OPEN TO BELOW) '4�)}( N,DEMO WALL AND REMOVE THE DOOR
HISTORY:
------------------- UP� I
I i i PERMIT
SET
I i I
BEDROOM#3
o I I I
I I 1 •
I I I NO. 03.16
I
I I I DATE 08.03.18
SCALE 1/4"=T-0"
BY JL
OC JL
J�)
PARTITION SCHEDULE: EXISTING
SECOND FLOOR
SECOND FLOOR PLAN To BE REMOVED
- 2 PROPOSED WALLS II
EX1 .2 i