HomeMy WebLinkAbout0058 HOLLINGSWORTH ROAD - Health f58`Hollingswoeth Road
� Osferville -F/R��-�ka ° . F } - •,r
A 140 `.075 IT,
a .
i
�r
No. Fee A
THE COMMONWEALTH OF MASSACHUSETTS Entered in com uter:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftplitation for Disposal 6pstem ConstrUttion Permit
Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. S� 44Ulf fM'jSwofN/N R�7 Owner's Name,Address,an Tel.No
c�S?F��iItE 1,AlrT MAVf�A/,Q
Assessor's Map/Parcel /Lto 1-7 S Pl^E
Installer's Name,Address,and Tel.No. S ug 4-32 Designer's Name,Address,and Tel.No.
SPE'kMA �cuvM tj if)C s� ,�N PL cr ik et,;.
Type of Building:
Dwelling No.of Bedrooms Lot Size r g gSZ sq.ft. Garbage Grinder( )
Other Type of Building ^ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) Lf(p) gpd Design flow provided Sfi t7 gpd
Plan Date l l 111 J l Number of sheets ) Revision Datej14/20
Title
Size of Septic Tank Type of S.A.S. C V"^13 CIS
Description of Soil �d�kA Aj
Nature of Repairs or Alterations(Answer when applicable) ADD P)p//V.f M� ZW7c
-Zb pn�P y x J4' SHO
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 Titl of the Enviromnental Cod and not to place the system in operation until a Certificate of
Compliance has been issued by this B of e Ith.
Si d Date S/1 1 Zn
Ap
plication Approved by Date jq&&)
Application Disapproved by Date
for the following reasons
Permit No. -90 00 l31. Date Issued 5 I q 1 7,,0"
No. 7,r�7n -" Cl Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION i TOWN OF BARNSTABLE, MASSACHUSETTS` Yes a
ftplication for ]3isposa1 ,4._ )pstrm C YCstructl0n Permit
V
Application for a Permit to Construct( Repair( )• Upgrade( ) Abandon( ) ElComplete System ElIndividual Components
Location Address or Lot No. • ,o R-r,; j?,> Owner's Name,Address,and Tel.No.
n 7,
Assessor's Map/Parcel )L- ,o
Installer's Name,Address,and Tel.No. j v�' (4_3 7 y . Designer's Name,Address,and Tel.No.
S17t A1(MFl� �` [r4UA/�/tf t_lC 55 661Jf
,Type of Building:
Dwelling No.of Bedrooms f6 Lot Size 1 11 `I' >i sq.ft.. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
t Design Flow(min.required) Cr U;_> gpd Design flow provided j y gpd
Plan Date 1 I A, 1/1 Number of sheets t Revision Date 4)7 o �
4
Title (C: 5 >1 rc s;1 A N
Size of Septic Tank 1(fit,o Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) A;,, V1 i 1AfS T 4/(j,1 i h�C i 57'A_1! ''a v t;
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Titl 55of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this,B-'oldd offHHe'a'lth.
-- i Signea tI.HC� Date t1 Zy
Application Approved by .r w.. .— Date
r r
Application Disapproved by Date
for the following reasons
Permit No. i7l� Date Issued S f 1 y o Z-0
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(�) Repaired( ) Upgraded( )
Abandoned( )by
at S, ?(fi II-r)-1 Ij i a has been constructed in accordance t
with the.provisions of Title 5 and the for Disposal System Construction Permit No. ( dated a)Lj'
F A
Installer �1?t. i�� N CA VA-71,,v Designer
' #bedrooms Approved design flo �-,/�y gpd
I r
The issuance of this permit shall not be construed as a guarantee that the system w' 1 chi n as desi ed. Q�
Date. �'12 y� �Y Inspector
----------- - --- ---------
No 2 � Fe0 / D
1 THE COMMONWEALTH OF MASSACHUSETTS `
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction Permit
Permission is hereby granted to Construct(jo Repair( ) Upgrade( ) Abandon( )
System located at ) t!1(_t 1,ir!t(,o 117!-t i
r
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this p i -
Date 1) 7 n Approved
TOWN OF BARNSTABLE
LOCATION 58 IV SEWAGE# 2Ol e? - 44-2
VILLAGE 03M-4LL ASSESSOR'S MAP&PARCEL 140 75-
3?
INSTALLER'S NAME&PHONE NO. �96442,Aw
SEPTIC TANK CAPACITY 1000 4A L- (&7 S7LA4)
LEACHING FACILITY.(type) GI'N0iml.1d2) (size)
NO.OF BEDROOMS 1+
OWNER 'hA-CnL(,4A P
PERMIT DATE: �I f � - COMPLIANCE DATE: ii a- �I
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED B
22,� .8�.
h
c
�4
r Town of Barnstalble
Regulatory Services
Thomas F. Geiler,Director
BAMSrABM
MAS& Public Health Division
0 9. 1�
TEn " Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 26 Sewage Permit# cQ01!1-aq).—Assessor's Map\Parcel 140 -7S
Designer: Nww CAPS ewJ�t�ug6l i C, Installer: !iftMkhM�N 15&CAVATlN LLC
Address: q 3q P-0UTr-;-(opt Address: I SPOIL WAY
yA(ZMourN EV
q,MA 7, HA"GCI i MA 02A5
On /ZZ V J 5P&*W q 4VA9Gkf was issued a permit to install a
(date) (installer)
septic system at 0 WLUNa5WO► T H Q O "ased on a design drawn by .
(address)
M 15L A. OJALA Pe dated _Nov. 25', zolq
/ (designer)
v I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved-changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State &Local Regulations.' Plan revision or
certified uilt by designer to follow.
OF Mq��cy
DANI�LA:
o OJALA
(Installer's a re) " CIVIL
No.46502
SS/ONAL'e
(Designer's Signature) / 11-7415 (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH !DIVISION. CERTIFICATE' OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.'THANK YOU.
Q:Health/Septic/Designer Certification Form 3-26-04.doc
. No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS S
RppliLation for Disposal 6pstrut Construction 3permit
Application for a Permit to Construct(A) Repair( ) Upgrade( ) Abandon( ) ❑Complete System 4KIndividual Components
Location Address or Lot No.S*9 �pQ o.P 0097y JZO Owner's Name,Address,a Te �.1o.
Assessor's Map/Parcel 1 O
I -rc- .W LCC �'1a��11+ N4 Y
Installer's Name,Address,and Tel.No. W_3ft6A Designer's Name,Address,and Tel.No.
S9E44k/10►t1N t5KC04%J10'e7oo "C 1)6&,m C14Ply �U.Nt?>fV-
/ Sc41+) i 3 7
Type of Building: G
Dwelling No.of Bedrooms Lot Size I�f V sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required)red) 't40 gpd Design flow provided S6 0 gp
iY-•-" /
Plan Date St 1►. °� Number of sheets 1 Revision Date // C
Title ?C.49- LA(V �
Size of Septic Tank Type of S.A.S. ► 3tW
Description of Soil See N _6L
Nature of Repairs or Alterations(Answer when applicable) —QUF 't �'�'2 v 500 At
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 Titl m nvironental e a not to place the system in operation until a Certificate.of
Compliance has been issued by this Bo of.I h.
Si Date -Z I/
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. 0 — Date Issued
Ael< :
No. V ( r i f Fee f -
THE COMMONWEALTH OF MASSACHUSETTS Entered;I computer:
Tom,
PUBLIC HEALTH' DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Y
ftplication for Misposal 6pst.rm Construction 3perm t
Application for a Permit to Construct(r)' Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. �.1 ULt A/p jU?7'1 i?_> Owner's Name,Address,and Tel.No.
t-t�urrlb,'�nr"'
Assessor's Map/Parcel j 4{j 71
Installer's Name,Address,and Tel.No. SdfA YA A1'4 Designer's Name,Address,and Tel.No.
4-(P
w1,Sf, o, 433 /"/A✓ S7.
TI pe of Building:
Dwelling No.of Bedrooms Lot Size / sq.ft. Garbage Grinder( )
Other Type of Building r No.of Persons Showers( ) Cafeteria( )
Other Fixtures T
Design Flow(min.required) 4•40 gpd Design flow provided 56 U gpd
Plan Date t 1«r # 1 "1 Number of sheets Revision Date
Title f! %C.f S( ;rt 1/
Size of Septic Tank 1 rt_?�'ISi +�r') Type of S.A.S.
Description of Soil CZ:
Nature of Repairs or Alterations(Answer when applicable) 1F r' 2 v ov �, [ (t z�n ��4)Z
v�
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--5aof=the EEnvironmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Si ed �,''.�!�r� n Date
Application Approved by J• (A Date h i
(
Application Disapproved by(l Date
for the following reasons
Permit No. 0 t Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed Repaired( ) Upgraded( )
Abandoned( )by S}�1= �!Vt v Ly CA VA-7V,f L.C C
C r�- Z - has been constructed in accordance
at S�- j!'1 GC.( �.�s sv y�2`7- 1 ` �,
with the provisions of Title 5 and the for Disposal System Construction Permit No. .1 U T U Ydated ) 2/ 9
Installer / Designer
#bedrooms L) Approved design flow 0 gpd
The issuance of thi's pe it shall not be construed as a guarantee that the system�M,,
as d�signed. c
Date I 6 Inspector �s
C F v
No. V C/� Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction APermit
Permission is hereby granted to Construct(+�) Repair( ) Upgrade( ) Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be lot
mpleted within three years of the date of this permit.
Date ( .� Approved by �jv
5�
4 _
MnW?52019�;mil:,f1q
f�
wATm1%RR
SYSTEM
N T o PROFILE
NOTES
iRmw D
Y[m fox HnuRE LouiaN. t.DAIUY rs RW1928
ACCESS CRFAS ro IwIMx N.OPIIK COIKYRR COwRS ro NRMx]•fJVDE S. I—.WATER IS EAB1M4
TOP FOUND.EL.30.5' cePusiO•¢OR cmT[mf
Tce f�BRlt OI4A STONE NNIWY PIPE PNCx TD RE I. /B-PER
Ei SLOPE REWARD ONOI 9TSIEY 29.1 OAMxO FOR ALL PROPOSED.PRECAST
ERTFST O'BOv fOR IM1HF54 UMR ro RE AASHO N-2D
. - 0°•�'xD v w/.i TNICNNESS mw 1 YIN.SWILL
].65' IMF Y ilAx�i lS S.PPE JgNTS ro BE T wATERTWT.
1RERT IN]5
DWSTRYCDW OETI65 TO BE W ACmROUICE � O
TEE sEJ•rc -�¢ �.. ��� ]t0 CMR Ix000(DnE S)
B.St•' E•m SU 7.M IW9 Pox 15 fW PR605fp YtlU(011lr AND
W 2 ',wL OY ONOTTOSEU
MER FOR mT LOU STANWD OR ANY
;.•••. .•.. '..•. -••.: n-m[vo Ow IFAoeAt PIWmD n.Nx wEMst oR[
L•'-�-In'ma[NYP[O smN[N'ut. (•1 uwn REORUD S.Wf fW ffPOC SY41Eu TO SCX.4D-4-Pm
otERxE OMp90rD TO a SIOx[.IVDO.ILN R.COYPOxENR NOT To BE BACIOILLm OR Nantucket
e'CRYMRp STONE OR I x CWCENED MTXWT INSPECRON BY SOAAD OF
m_oN.(I].]]T(]D HEALTH AND PERMISSION....FROM BOARD SOunJ
L-w SLOPE) (LA 9L OF HEALTH.
P[) t0.-TER SNALL SE RE4W98tE fM ..
FOUNDATION— EXIST.—SEPTIC TANK— 87' —0'BOX I6' LEACHING x0 wav[xuTm rourm IO]MF fl-ems-»e-Tv])AND LOCUS MAP
NXSTAUDE SNNL COWVW YDIIYYY 9PDD TAxN 92E AT FACILITY TERFTvtO THE IOCA OF Au UxOER"D
•rHE IxSrAutA snNl IRS,�ILCATpIS�Au - wrn�N.AD UNIJTES PRIO,To Co—..T OF SCALE 1•.2000't
txRITRS Axp ALL BIRpNG SLYER OUIEflS AND flfl•AlMxJS •DEO CNLWS AND ITS SUITABILITY FOR RE-USE. —OE -ON SEPT.PORD OR 10 NSNTABLE YASpDAL EXCgW1FPFD SHALL ASSESSORS MAP 1W PARCEL 75
PWI LUNG AM' ON Of-D, —1 SYSIEu 500 0.5IL TANK—..ATE TO AR ANY U
COxMOONS R NET SUTARIE RE RE_ IENEAM AND 6'—D THE
PROPOSED lf—D FACWT LOWS IS WITHIN FEMA FLOOD ZONE%
(AREA OF MINIMAL FLOOD HAZARD)AS
t7,EYSDNO LEACwxO FAOUTY SNAL.BE PUUPED SHOWN ON COMMUNITY PANEL 125001CO757J
LEGEND ANEDEREMP OR PDMPSO AND RDED S"'EE N DATED 7/16/2014
--[- [YlsnNc LOMWP IJ.POOL KNEE SNAIL NAPE SELI'-CLOSMO
v sE1r-uTcxlxc"TES.DZE Axo MAT"A"TD
X cet (1¢St SPOT , EFi S STAR RTo PO L SNALLLS
-ME DOORS Oq]JIHC ro POOL SXALL BC
AURYm ro CODE.
lvA4l PROPDsm sm n —`/.--2`..1 V \)1)
0 RM NDL SYSTEM DESIGN: .
N8510'4I-W A�
i SLOPE o, 0. M.4BCUHc GARBAGE DISPOSER IS NOT ALLOWED
177.21'
DESIGN FLOW:4 BEDROOMS 0 110 CPO 140 GPO -
IT O - LOT 5A ]E (\ USE A 440 GPO DESIGN FLOW
19,9523 S.F. c
Nrr-w O SEPTIC TANK:44�Q CPO(2)_.BBy,
USE EXISTING 1000 CAL SEPTIC TANK
TEST HOLE LOGS D wR LEACHCn ING:
3T$ OI]0 SIDES:2(42.0 H 12.83)2 L74)-162.2 CPO
ENGINEER:DANIEL E.GONSALVES.SE/13587 O ;A -
w ® BOTTOM 42.0 x 12.83(.74) CP 39].e O
WITNESS:DAVID STANTON,RS ,� - _
TOTAL: 757 S.F. 580 CPO
DATE: I1/5/19 Ir-.-]N I.—ED I 1 ,• USE(4)500 GAL.LEACHING CHAMBERS(ACME OR EQUAL)
<5 MIN/INCH W % 35'x - N g POoI
E
CLASS
RATE-S I SOBS P/ 19 190 pw— WITH 4.0'STONE ALL AROUND
E NG _� I1'•o
roc-w s
ELEV. ELEV.
A A MA
LS LS \. I APPROVED GATE BOARO OF HEALTH
12•
IOYR 4/3 11• IOYR 4/3 AnO(St. TITLE 5 SITE PLAN
\` �KRN CARADE �}}'-P W��f
B B �`m[\ SUB.l9s a I+ D,�• N - OF
L5 • Ilag #58 HOLLINGSWORTH ROAD
28' TOMB 6/6 26.7, 10Yfl 8/e _
z°- z6.7• D OSTERVILLE, MA
CB Ox M
C D •Tp S88'18'33•W '170.53 - PREPARED MR.
l// Q, caw/"v/"L-,^ - J J/^ '• SHORELINE POOLS
M/FS M/FS I J 'O-a \\ I Y',,...... 2010
DATE:TNOvNB�20.t20 9(W)
`"'� l { �y rye DATE NOVEUBER 25.201
9
(SAS GET.)
2.SY 7/1 2.5Y 7/4 N EL Et yq�11 50E-]ex-45
11
OJAU I�J.eve 500-Mc-SBGO
EvOJNA'A• FA' Y T e aP, m
wer egpa�n�t�ierin�inr.
128' WATT 128' civil engineers
xDlBn•=zo' _ land surve NO GROUNDWATER ENCOUNTERED _J� o yor5
DATE pgNIEL A.OJALA,P.E.,P.LS. / 9J9 MOin Street(RYfe BA)
DCE y 19-369 D FE-T VARMOUINPORT 02625
v.Dw
TOWN OF BARNSTABLE
LOCATION ��A/d/,6A09 WOAr SEWAGE #
VILLAGE [ems IP-vi 11.e ASSESSOR'S MAP & LOT d` 7
INSTALLER'S NAME&PHONE NO. i1.)kAt 14 4d4 I/1,e Ile Li
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS_
BUILDER OR OWNER W±tiAl
PERMITDATE: a 2 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) 1 o cd'y Feet
Edge of Wetland and Leaching Facility(If any wetlands exist ���® Feet
within 300 feet of leachi g facility)
Furnished by
1
�ti�
M
�x^
n
�3v�k pew
off' }leas�
�� �:
~ N�. ?_o0 3---07,4 �" ►' • j Fee
�. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
-, Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for Migpogat &pgtem Congtruction Permit
Application for a Permit to Construct( . )RepairKUpgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. 5 o ups,.�o �d Owner's Name,Addree sand Tel.NN
Assessor's Map/Parcel
i o-17�s
Installer's Name,Address,and Tel.No. 5 d M� Designer's Name,Address an Tel.No.
Jr i9 P spy sr Vr 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 Of _
Size of Septic Tanks —LO Type of S.A.S. q
f
Description of Soil
S
Nature of Repairs or Alterations(Answer when applicable) �i
,Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of TitleAo .�environmental Code and not to place the system in operation until a ertifi-
cate of Compliance has been' su by thf Health.
Signed Date o4 3
Application Approved by Date 2 2 0 3
Application Disapproved for th following reasons
`' --PermitNo� ?BOO 3 07 —_------- Date Issued --- Za G�------
" 'jv � 3 Q< b �. „, Fee Entered in computer:
' _
THE COMMONWEALTH OF MASSACHUSETTS --
Yes
` \ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
~ ricatior� f� origooar *p9tent Con!Aructonerrrttt
=
Application for a Permit to Construct( . )RepairKUpgrade( )Abandon(, ) ❑Complete System ❑Individual Components
Location Address or Lot No. A., vss tq, ➢� 1!,4 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 0,,'fo t^N
00-0 75
Installer's Name,Address,and Tel.No. — dn+(�S Designer's Name,Address and Tel.No.
l l I�'S � s���s o.v tl�/� t
. 6d / A WL I)�� C�STIovw,x `fo sly
7
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 2-0 Type of S.A.S. y r
Description of Soil 'r�x 3 L A r
S aTic�
Nature of Repairs or Alterations(Answer when applicable)
,nA
Date last insp1cted:
Agreement: �l
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of TitlZ5o he Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has bee sued"by td of Health.
Signed Date r3 3
Application Approved by Date 2 2 q a 3-
Application Disapproved for the following reasons
Permit No. 7 O 3 6r7(. Date Issued12 q G 3
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
r
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired K)Upgraded( )
Abandoned(, + )by {{{{yy//// ��\��\
at 5--Ai �tinrW o, r'f` . has been construcd in cordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ZOO 3 07 L dated 7-7 z C 3
Installer Designer
The issuance of s peirmiit shall not be construed as a guarantee that the syste do designed.
tJ.,�.•;Daier Z�lb Inspector
---------------------------------------
No. 2 U0'3-D (V Fee J V
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
�Dig;pogaf *potent Conotruction Permit
Permission is hereby granted to o eruct( )Re 'r Upgrade( )Abandon( )
System located at �� f e A Stj 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: Constru tion st be completed within three years of the date of this pe i.
Date:_ 2 2 D3 Approved by
1 .
i
TOWN OF BARNSTABLE
LOCATION ,� ,��
� ®��.� �Y' � � SEWAGE # .2043- a 7�
VILLAGE 1 PP/`Vt I f ASSESSOR'S MAP &_LOT y0 7�
INSTALLER'S NAME&PHONE NO. %?Q I+Q L-7
SEPTIC TANK CAPACITY /G`0® Cr4�.
LEACHING FACILrIY: (type) (size) /A X VZ)
NO. OF BEDROOMS y0
BUILDER OR OWNER t�t/�� �/ LJIA,(
PERMITDATE: COMPLIANCE DATE: 2/29/d✓�
i
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 0-6 Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) yo_I,JN Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachij�g fa ility) /-0010 Feet
Furnished by
'off
, C � J
M
f i
_ ......
�
FEB 2 G ENtD
Town of Barnstable P# /b � S
P�o��t+e rok,o
Department of Regulatory Services
Pate
9A Pub th Division
lic•Heal .
o'���� 200 Main Street;$yannis MA 02601
TFOIMy
Time
Date Scheduled-4+
��--- Fee Pd.
• suitability sessment or Sewage Disposal
Soil Suitability As f
• ram.-�..,. )� /t
Witnessed By:
Performed By: , 4
IT � gyp. •ay." I, n�''q Ias
kInl�+'ll 4a�tlllYy�B 1'All Ldl 1104, 6'iF111..f
H1WlMillkY�i'ICI¢n ; I � (�
ma's Nam
Location Address �� pY�'^�E^�`�I
j Address �inl�t
ps4rdle S6
Engineer's Name ��`1
Assessor's Map/Parcel: j q p—67 S . •� /�o
REPAIR Telephone#
NEW CONSTRUCTION
Land Use f r T Pt /�
Slopes(%) Surface Stones•_
Drinking Water We11
'Fft Possible Wet Area—ft T/��ft .
Distances from: Open Water Body � � ft
t ft Other
Drainage Way /✓eft Property Line ,�--—
H: Street name,dimensions of lot°exact locations of test holes&pert tests,locate wetlands in proximity to holes)
5KETC ( .
•
�// ,rf
Depth to Bedrock .�®�J
• ///�r ,� �i7TF ��°tii
Parent material(geologic) —
d� /
Weeping from.PitFace dpai/r j
Depth to Groundwater: Standing Water in Hole: i✓onl�!�L
Estimated Seasonal High Groundwater
rG"s,F
'm�i I'�1;i.i'�I'.'' �ry 5' , I'� A A.o .t ' _� �t�. WN
<
III; I'�hryV 'fr..`I 1 v
� , : �
in.
Method Used: in. Depth to soil mottles: ft.
Depth Observed standing in obs.hole: in. Groundwater Adjustment
Depth to weeping from side of obs.hole: Adj.fac torte—Adj..Groundwater Level_
# Reading Date: Index Well level
e Well +,y
Ind x -- .
t N, l , I i
,,. I "All
i'
s 6yt4l1141 1� I !It�� k
Observation Time•at Sr'
/ —
Hole# i . .
Time at 6"
Depth of Pere
--
Time(9"-6") —
Start Pre-soak Time® ��
End Pre-soak
Rate Min./inch
Additional Testing Needed(YIN)
Site Failed:
Site Suitability Assessment Site Passed —
._._,+ ¢�Tn Rc Completed on Back
,-j.
�fI I��Nt�' Pu��'�'I,•.. 'vI rh � �.. r 7 nt�cA,, !. e� i .:.•i� � . '�' I���! ,' �: '� '�J��iI�CI�W .
pepth from Soil Horizon: Soil Texture Soil Color Soil Outer
Surface fin.) (USDA) (Munsell) Molding Structure,Stones,Boulders.
Consistenc d%Gravel)
'
97 Y Ga Fint�.d'q.✓p /6?/s� 7/2 — .
17 B r �� �'�✓�. 7,SIR
�¢ ;.',
Soil Other
Depth�from Soil Horizon Soil Texture Soil Color Molding structure,Stones,Boulders.
Surface(in.) (USDA) (Munsell) g Consistency,%Gravel
-I a Fti�
'��:"f`y'•.)a'1xk ,? k.k. #" , .. rT, ns�i� -'�,; r ��P !7 :�'�. _I �7... W'.. I .IM:.
{ '����� � �. �! r 1 Y.. ''aap... .� •�'•ny :I. Soil I, •'
Depth from Soil Horizon Soil Texture Soil Color Mottling Structure,Stones,Boulders.
Surface fin.) (USDA) (Munseil) Consistency,%Gravel
y G 1��r l' � u � �u,� •t a e I,! :A ,�Ic• 'n� � 'I '',�';�'!�.� �1,@,�' '"�'f jl,r,l lm 1,��:.'F�� _�nI�`I'��,p.
! § `9' .�•' �• 1 ;".r I I. .. ! f ;�, aria '
Depth from Soil Horizon Soil Texture Soil Colar Soil Other
Mottling Structure,Stones,Boulders.
Surface(in.) (USDA) (Mansell Consistency,%Gravel
-------------
Flood Insurance hate Map:
Above 500 year flood boundary No_ Yes
Within 500 year bouadaty No _ Yes
Within too year flood boundaty No_ Yes
Depth of Naturally Occurring Pervious Material.
Does at least four feet ofnaturally occurring perviou material exist in all areas-Observed throughout the
area proposed for the soil absorption system?
Ifnot,what is the depth of naturally occurring-Fe al?
Certification
I certify that on %/ (date)T have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the•required training,expertise and experience described in 310 CMR 15.017.
4 Building Sketch (Page - a)
Borrower/Client :UftanerFamily
Property Address 58 Hollingsworth Rd
Cfty Bamstable County Barnstable State Me Zip Code 02655-2103
Lender McLane Family
r — _
�-i i -.- r ^{-c -}.. t I S �11 f t j-.t,-+ y ' ' T t t I I ._!..
4:0
.i r!
! t--}- r ' --�-t'_'-✓.-' rt ' -t' t ` t ! 'rr
'i
is
`L family Room Deck
1 ( r!-. { I +i .r { i, F Q s 3 `S'•`s L i a r i , I i ' !.�
it -�T r!� r
T' '-
r
JY . T'�
I_.�'_t_t-t-5-
r, t + 1T �fi�-�j � iI Jt i ii 1 �TLtt.
-r-
I *i T _68th i l 1 if t i i t I f a i 1 r r
ram_, 7t 1r �'
t _L i
+ r ~� ng L, y 4-Kitchen , J 1 ri.
H r t i L Laundry
w.- ,LT'j.
i 1 ; --r-{-' I r-r ,-i t 1 1 ` r 7 ` 1 1 1 f` T`I._ `t'"
L T � t` _i �- r
'? i j -4-.�ELT t :-- - i f i i `L l..t_.
I,I
{'1 t ��_"_"� -'V t 4 1 '•T I t ,. .t... �. -r-l�r , i�k �-I i� , i �-r-r-I `-��.�i._
,l ii-��� -}-�-- '--y 1-�..�L,�yL��'i 1,��_ �. t i L I i r�J i J..-•� t -_i -},� I t.L T_ ODD {.*7.r���1 � I I.J j�j i i i`��
i.� r_ fii , L, ,_L: �->-+•.-� r_e.yr....- ..1.!.�¢
r�
t '�� � 'I-I`- I - t 'Y�L-�-a
a Living Room (� +' r t T i i f'� 1 -r L r'*", , F t N ! T Bedroom v-T+
,
•.�
Ltt 1T1 + i �1-H
;-+-r -j� 1 [a r t��1�'
f � _ + � ' t
;
-: t-
, (_.. �-r , _I , I^t I�. fi } i t �.'_ f ( -�a--Y �f-i r r- t - I � � i r i`}T t I�'� Y I �� 't.t.t. * r i• , r.-r r-1..
'1- ��-•-i-
L
-'--j- -lyi
-
��
- r �r. ,'•�"��hir i� � � f � � a!_Iti, �_:ri.J �_
t._ edrOOfTi
'� - — p r J _ 7
+-i r'T-,-( , i`} 1 i i ( ' 1 , .'i i
+1_f"�_I r i -{-I.x--+-f• ' F'-i v -{ ' '-{ ' .J V-� - '- v !�r_{_.� �.- t b , :�. i! �_Y
r'.-..�.Yl �.. i-
'i r' } _ , F I r. Bedroom r( t . �� �} }r a t T_
i 1 1 l .lh-
}i I i 4 I f a 1 I N.. Closet F { t
I. ..�. 1 r F.i.-1-.{-1.... . .�.�. 1.�_I _.�.., er.. r .�_� �--a ' , a i {.�_.
I r 41
�'! 17�, i {. . i ir-L+_.'t '-T1-� ''r t r i--f-(•-f`y, '-� i I 'r 4�.dr i'!-T".' 5--- 7 q-'t I t , I tTi-,�`I.r Jr 1""1 t.
J 1 --:-}.-1-:_,��1IL..I. i 711 -1 i
--
&Iaraw�»rm� H-- -_ J I 1 u .' 1;�1
!_.i..;.._...ii_i. ��.�_ �.i.r1.�.J_..__!�_�::.L!T j._iT�_t�_1J.� 1 _ .��.�yLl.f!.....-_l ru.-i_ .�.___
Comments:
AREA CALCULATIONS SUMMARY LIVING AREA BREAKDOWN
Code Description Net size Net Totals Breakdown Subtotals
GLAl First Floor 1316.0 1316.0 First Floor
GLA2 Second Floor 840.0 840.0 28.0 x 40.0 1120.0.
BSt4T Basement 1120.0 1120.0 14.0 x` 14.0 196.0
Second Floor
21.0 x 40.0 840.0
Commonwealth of Massachusetts
4 W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osterville Ma. 02655 5/15/2009
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information I
When filling out n b
forms on the J
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
f� P.O.Box 763
Company Address
Centerville Ma. 02632
°0A City/Town State Zip Code
(508)428-4028 S14454
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
5/15/2009
Id9kect&Ps 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.
LO
o�
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osterville Ma. 02655 5/15/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
^M 58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osterville Ma. 02655 5/15/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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): i
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 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
58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osterville Ma. 02655 5/15/2009
every 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: i
**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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osterville Ma. 02655 5/15/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® 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,OO,Ogpd.
❑ ® 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osterville Ma. 02655 5/15/2009
every page. Cityrrown 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 d x#of bedrooms): 440
( P 9P )
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osterville Ma. 02655 5/15/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1500 gallon septic tank,distribution box and leaching field.
Number of current residents: 2
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
1
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2007:78,000
g ( y g (gpd)): 2008:46,000
Detail:
2007:213 gpd 2008:126 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: 5/15/2009
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
I .
Commonwealth of.Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osterville Ma. 02655 5/15/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osterville Ma. 02655 5/15/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2003
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 14"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 20'+feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
's
Septic Tank (locate on site plan):
2'
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: 1500
Sludge depth:
3"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official, Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osterville Ma. 02655 5/15/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
2"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
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•09/08 Title 5 Official 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
�H 58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osteryille Ma. 02655 5/15/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osterville Ma. 02655 5/15/2009
every 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 No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage into or
out of box.
I
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 (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osterville Ma. 02655 5/15/2009
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 12'x40'
❑ 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.):
Sandy dry soil.No signs of hydraulic failure.No ponding or damp sol.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osterville Ma. 02655 5/15/2009
every 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.):
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
.'' 58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osterville Ma. 02655 5/15/2009
every page. Cityrrown 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
a qnatf. •lp
w
i
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osterville Ma. 02655 5/15/2009
every 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: Bottom of leaching 20'
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: 2003
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
As-Built Card.
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 58 Hollingsworth Rd.
Property Address
Roy Lithwin
Owner Owner's Name
information is required for Osterville Ma. 02655 5/15/2009
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
f
TROY WILLIAMS J
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection FAME® (508) 385-1300
19 Hummel Drive INSPECTION
South Dennis, MA 02660
COMMONWEALTH OF MASSACHUSETI'S
EXECUTIVE. OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
"TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM--
PART A I�EC-IVED
CERTIFICATION
u U032002
ProperiN Address: 58 Hollingsworth Road
Osterville,MA TOWN OF BARNSTABLE
Owner's Name: Scott McLane
ALTH DEPT.
Owner's Addres,: 58 Hollingsworth Road ,
Osterville,MA 02632
Date of Inspection: November 13,2002 O
Name of Inspector: . Troy M. Williams i 1 l Il
Company Name: Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive
South Dennis,MA 02660
Telephone Number: (5A)385-1300 9 15
CERTIFICATION STATEMENT
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 svctenv
Passes
Conditionally Passes
Needs Further Evaluation by the I-ocal Approving Authont�
Fails
Inspector's Signature: IJ
Date: i f/r 3 /0 2
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of 1 iealth or
DEP)within 30 days of completing this inspection. If(lie 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.
Notes and Comments
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification Is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
""This report only describes conditions at the time of inspection and under the conditions of use at that
time. phis inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 paee 1
' Page 2 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
58 Hollingsworth Road
Owner: Osterville,MA
Date of Inspection: Scott McLane
November 13,2002
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 v of the failure criteria described in 310 CNIR
15.303 or in 310 CMR 15.304 exist. Any failure criteria n evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be repl d or
repaired. The system, upon completion of the replacement or repair,as approved by the Board of He th, will pass.
Answer yes. no or not determined(Y,N,ND)in the_ for the following statements. If" t determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank.(whethe etal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imm' rnt. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the and of Health.
•A metal septic tank will pass inspection if it is structurally sound,not aking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or gh static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or un en distribution box. System will pass inspection if(with
approval of Board of Health):
broke tpe(s)are replaced
obs ction is removed
stribution box is leveled or replaced
ND explain:
The system re ed pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if approval of the Board of Health): i
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
58 Hollingsworth Road
Owner: Osterville,MA
Date of Inspection: Scott McLane
November 13,2002
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 03(1)(b)that the
system is not functioning in a manner which will protect public health,safety and a 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 alt marsh
2. System will fail unless the Board of Health (and Public ater Supplier, if any)determines that the
system is functioning in a manner that protects the publi ealth,safety and environment:
_ The system has a septic tank and soil absorpt' system(SAS)and the SAS is within 100 feet of a
surface %%titer supply or tributary to a surface w- er supply.
The system has a septic tank and S and the SAS is within a Zone I of a public water supply.
The system has a septic tank d SAS and the SAS is within 50 feet of a private %eater supply well.
_ The system has a septic nk and SAS and the SAS is less than 100 feet but 50 feet or more hone a
private water supply well* . Method used to determine distance
"This system pass if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and vol a organic compounds indicates that the well is free from pollution from that facility and
the presence ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure cr' ria are triggered.A copy of the analysis must be attached to this form.
3. Other:
i
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 58 Hollingsworth Road
Osterville,MA
Owner: Scott McLane
Date of Inspection: November 13,2002
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
_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
_Z 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 I of a public well.
__ ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
f 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis iuust be attached to this form.)
`(C> (Yes/No)The system fails. l 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.
O�i. -/ Qv,.i//c/ Ca S S fJ.,..( Wc..g �_..l V.,)-}sib/4 o-.,./� � .. J-.-.,j....� old' Gam.✓c :N .
E. Large Systems:
To be considered a large system the system must serve a facility with a des' n now of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteri above)
yes no
the system is within 400 feet of a surface drinking ter supply
the system is within 200 feet of a tributary t surface drinking water supply
the system is located in a nitrogen se ive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply w
If you have ilttswered"yes"to any qu . ton in Section E the system is considered a significant threat,or answered
"yes"in Sectign D above the urge stem has failed.The ownor or operator of any large systettt considered a
significant tl}reat under Section or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner s Id contact the appropriate rcgiogal office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
58 Hollingsworth Road
Owner: Osterville,MA
Date of inspection: Scott McLane
November 13,2002
Check if the following have been done. You must indicate"yes"or"no"as to each of the followine:
Yes No
_ P..; ,l-,ing information was provided by the owner. occupant, or Board of I leald,
Were any of the system components pumped out in the previous two wceks?
— 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?
— &L 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
_ A (i9 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?
1
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:
Yes no
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(3)(b))
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
58 Hollingsworth Road
Owner: Osterville,MA
Date of inspection: Scott McLane
November 13,2K2OW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): `/ Number of bedrooms(actual): 'Y
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 'yv6
Number of current residents: a
Does residence have a garbage grinder(yes or no):Alo
Is laundn on a srl)arate sewage system(yes or no):ivo [if ves separate inspection required]
Laundry system inspected(yes or no):A1/,1
Seasonal use:(yes or no): Alu
Water meter readings, if available(last 2 yearshsage(gpd)): o
Sump pump(yes or no): my
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.): _
Grease trap present(yes or no):_
Industrial waste holding tatilt present(yes or no):_
Non-sanitary waste discharged to the Title 5 system es or no):_
Water meter readings, if available: _
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: o
Was system pumped as pan of the insp ction(yes or 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)
)
_Tight tank —Attach a copy of the DEP approval
_Other(describe):.
Approximate age of all components. date installed(if known)and source of information:
CUvc �� r✓ o P of a��y,,� �Oy,�-r
Were sewage odors detected when arriving at the site(yes or no): .fu
6
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
58 Hollingsworth Road
Owner: Osterville,MA
Date of Inspection: Scott McLane
November 13,2002
BUILDING SEWER(locate on site plan)
Depth belo�k grade: r6 " +
Materials of construction: cast iron —40 PVC/ _other(explain):Qr�u 1k .
[loaner frorr, private water supply well or suction line: w[9
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: —(locate on site plan)
Depth below grade:
Material of construction:—concrete—/beberglass—polye ene
—other(explain)
If tank is metal list age:_ is age confertificate of mpliance(yes or no):'' (attach a copy of
certificate)
Dimensions:
Sludge depth _Distance from top of sludge to bottom ofaftle:Scum thickness:
Distance from top of scum to top of outle. _Distance from bottom of scum to bottomor baffle
I low were dimensions determined:
Comments(on pumping recommenda ' ns, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence f leakage,etc.):
GREASE TRAP:_(locate on site plan)
Depth below grade:—
Material of construction:—concrete metal fiberglass_po ethylene_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 or baffle:
Date of last pumping: i
Comments(on pumping recommendations ' et and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of le age,etc.):
7
Page 8 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
58 Hollingsworth Road
Owner: Osterville,MA
Date of Inspection: Scott McLane
November 13,2002
TIGHT or HOLDING TANK: (tank must be pumped at time of spection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fibergl s__polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flo\%: gallons/day
Alarm present(yes or no):
Alarm level:— Alarm in working er(yes or no):
Date of last pumping:
Comments(condition of alarm and oat switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(loc a on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to o is equal,any evidence of solids carrygver, any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: —(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition pumps and appurtenances,etc.):
8 .
Page 9 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
58 Hollingsworth Road
Owner: Osterville,MA
Date of inspection: Scott McLane
November 13,2002
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why
Type / w• n, �.�,,.i a
leaching pits. number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number: k
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,L'ondition of vegetation,
etc.):
Ll✓e r T-�o� -..L�� S O u o ( �J<�� ,T�.-�_'�.---fe�y�1 �e f'e.( ti__� -, �—K) ti v� u N u1
(../�:7--Z=�-s � ✓^ S -�T b �2-._—: W.^.}w _�yJ/.c.l �c„� c ,►.•� ( �+�5
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:_vim 4a.s any
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum la%er:
Dimensions of cesspool: j;-;Lrs '
Materials of construction: CC-S %",,') t 6/o
Indication of groundwater inflow()es or no): __,Azo
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
( W'. .* i,,—'e-— /",/—(
.t .A-,
PRIVY: (locate on site plan)
Materials of construction:
Dimensions: — ----"--- — ---
Depth of solids:
Comments(note condition of soil,signs of hydr tc failure, level of ponding,condition of vegetation,etc.):
T X.
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 58 Hollingsworth Road
Osterville,NM "
Owner: Scott McLane
Date of Inspection: November 13,2002
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
I v
I
l
i
A//
�w�ti
Page I I of I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
58 Hollingsworth Road
Owner: Osterville,MA
Date of Inspection: Scott McLane
November 13,2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 2`•Z feet
--- Adjusted high ground water elevation ,2Z,9 feet
Please indicate(check)all methods used to determine the high ground %cater elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
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: L,:✓z y z
Y
You must describe how you
established the high ground water elevation:
)2_ 0 '
This report has been prepared and the system inspected as of the date of inspection. This report is not a
warranty or guarantee that the system will function properly in the future. There have been no warranties or
guarantees,either expressed,written.or Implied, relating to the system,the inspection and/or this report.
-- - -_- f _NEW DORMER I_--
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MOTE:
WINDOW DFSIGNATIONS ARE
ANDERSEN WINDO'r15.
f CONTRACTOR SMALL VERIFY
LOCATIONS 4 DIMENSIONS PRIOR SUEET I OF 4
TO WINDOW ORDER 4 INSTALLATION
SECOND FLOOR PLAN
SCALE: 1/4" m I'-O"
NEW WALL
REMOVED WALLC_______-!
EXISTING WALL JOB: OB04
DRAWN BY: KW
DATE: 12/18/09
I
' n
f
O
NEW DORMER —I
W
r
12
YYP- ROOF \
2x10'e 0 16' O.G.
R30 F.G. INSUL./+ 5/8` PLYWOOD SHEATHING/ IL'111
ASPHALT SHINGLES
(2) 2xI0m12
\- R30 F.G. INSUL.161-01
V (�
SIMPSON H2.5 TYP. EXTERIOR WALL
r h W \ FASTENERS AT ALL 2x4 EXT. STUDS 0 16° O.C./
iv M� �1 ',:II; \ RAFTER / TOP PLATE RIB F.G. INSUL./
{1 \ JUNCTIONS TYP, 1/2' PLYWOOD SWEATHING/ o (1
(2) 2xI0a TYYEK WRAP/W.C. SHINGLES
— — —(2) 2XIO RAFTERS EACH END OF DORMER }
EXISTING SECOND FLOOR SYSTEM co
—'- ----- IS'-4 1/2" r_
-- --- ug
m ' w Z
j,
E X15TING FIRST FLOOR SYSTEM
EXISTING GIRT • -
3 1/2' LALLY COLUMN—;
26'
N 1 _
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v
Gf ®�� S G�'!ON _ ww
SCALE: 1/4" ® 1'-O"
OD o
LID
SHEET 1 OF 4.
t!
u
JOB: OgO4
DRAWN BY: KW
- DATE: 12/11 a/oq
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or
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0 7-
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7
TOP OF FOUNDATION
CONCRETE COVERS
"77--MrTr.+'
I
. . I " c,— -, i
IRON
4 CA SiT I W6� 'i ,,
4"SCHEDULE 40 P.V.C. (ONLY) 9. MIN . LEACHING TRENCH )REO.
OR SCHEDULE 40
..A P.V.C. PIPE MIN. PIPE- MIN. Ila,,_ 112, WASHED STONE 3 " MAX.
If ITCH 1/4"PER.Fr
I-P PITCH 1/4"PER.FT.
"011 I-Eg
to
INVERT 1.1'0
INVERT INVERT 24
DIS
SEPTICTANK
EnlL . .
A INVERT BOX*
GAL.. INV RT
/ INVERT
EL. EL ." .,.
0, p EL TM
17 -STONE am t�r
6 CRUSHED
PROFI LE 0 F e&,
4k, GROUUD WATER TABLE e�lc
'v SEWAGE DISPOSAL SYSTEM TYPICAL CROSS_
SECTION
SOIL ' LO NO SCALE LEACHING TRENCH
11-1 ✓ NO SCALE
DATE7?�,�&4. TIME
R0A L' TEST HOLE I TEST HOLE 2
7r DESIGN DATA
ELEV. ELEV. "AIN. I/Z"
9 to
WASHED 36 MAX
NUISABER Or BEDROOMS
f-4 L L I
TOTAL
ESTIMATED FLOW GALLONS/DAY
4"
BOTTOM LEACHING AREA S0.FT./TR=NCH
24
c' SIDE LEACHING AREA 50.FT./TRENCH
GARBAGE DISPOSAL 9% AREA INCREASE)
iS1 i TOTAL LEACHING AREA SQ.FT.
9 L
PERCOLATION RATE Nd1z; . . .LEACHING AREA PER PERCOLATION RATE SO.1
/'XG GROUND WATER 'rZ?LE
es:- APPROVED BOARD OF HEALTH
..!'�<i..WATER ENCOUNTERED DATE IA OF 444
AGENT OR INSPECTOR
WITNESSED BY '.
STETS N
R.
7.1 /Z OF HEALTH
-7 BOARD
AL
ENGINEER N .5; 7
101
r7lr
2 PENTIONER
4-Z6 . . . . . . . . . . . . .
SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE NOTES -T--
MARKED WITH MAGNETIC TAPE OR
(NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS NAVD 88
PROVIDE MIN. 20" DIAM. WATERTIGHT WATER IS
ACCESS COVERS TO WITHIN 6' OF FIN. GRADE 2" pEASTONE OR GEOTEXTILE CONCRETE COVERS TO WITHIN 3" GRADE 2. MUNICIPALEXISTING _L
\ TOP FOUND. EL. 30.5' FILTER FABRIC OVER STONE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. esti a �0��5 East Bay
MINIMUM .75' OF COVER OVER PRECAST F2% SLOPE REQUIRED OVER SYSTEM 29.1 ' 4. DESIGN LOADING FOR ALL PROPOSED PRECAST o�
WATERTEST D'BOX FOR LEVELNESS BLOCKS OR UNITS TO BE AASHO H-ZQ
PRECAST H-10
RISERS (TIP.) MIN. 2" WALL THICKNESS PRECAST RISERS
2'A 27 5. PIPE JOINTS TO BE MADE WATERTIGHT.85' 4"sbSCH40 PVC MORTAR ALL INVERT IN 25.12' Locus
PIPES LEVEL 1ST 2' 4 COMPONENTS
' (n P) 4
ENDS SIDES 26.12' WITHONSTRUCTION DETAILS TO BE IN ACCORDANCE
". 10" EXISTING +* 14" °° _ 310 CMR 15.000 (TITLE 5.) , ec von
TEE SEPTIC TANK TEE 26.3t* o °° ®®® ® m ' °°°°° k P
000000 6" MIN SUMP ° ° °. ® LI ® ® ° ° ° ' O
o�o.o0o�o �9R�1;R R ®8 ®H'IRR� °R�� 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND
GAS BAFFLE °o°0°oo 0oo 12" MIN. INT. DIM. °<-° ° ° °
23.12' NOT TO BE USED FOR LOT LINE STAKING OR ANY
25.43' S. 6' J OTHER PURPOSE.
_ _ °1° `-H-20 500 GAL. LEACHING CHAMBERS BY ACME PRECAST OR EQUAL 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. -j
3/4" 1 1/2" DOUBLE WASHED STONE 4' MIN. (4) UNITS REQUIRED
ALL AROUND PRECAST STRUCTURES N c n t u c k e t
OVERALL DIMENSIONS TO OUTSIDE OF STONE: 42.00' x 12.83' 9. COMPONENTS NOT TO BE BACKFILLED OR
6" CRUSHED STONE OR MECHANICAL n CONCEALED WITHOUT INSPECTION BY BOARD OF Sound
COMPACTION. (15.221 [21)
HEALTH AND PERMISSION OBTAINED FROM BOARD
OF HEALTH. --- b --- -
( 1 1 SLOPE) { x SLOPE) 10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP
1O BOTTOM TH-1 CALLING DIGSAFE (1-888-344-7233) AND
FOUNDATION- EXIST. SEPTIC TANK 87' D' BOX 16' LEACHING No GROUNDWATER FOUND FACILITY VERIFYING THE LOCATION OF ALL UNDERGROUND &
OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF SCALE 1"=2000't
*THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL "INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT WORK.
UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE ASSESSORS MAP 140 PARCEL 75
PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL
CONDITIONS IF NOT SUITABLE BE REMOVED BENEATH AND 5' AROUND THE LOCUS IS WITHIN FEMA FLOOD ZONE X
PROPOSED LEACHING FACILITY. (AREA OF MINIMAL FLOOD HAZARD) AS
12. EXISTING LEACHING FACILITY SHALL BE PUMPED SHOWN ON COMMUNITY PANEL #25001CO757J
LEGEND AND REMOVED OR PUMPED AND FILLED WITH CLEAN DATED 7/16/2014
SAND.
- 99 EXISTING CONTOUR 13. POOL FENCE SHALL HAVE SELF-CLOSING
SELF-LATCHING GATES, SIZE AND MATERIALS TO
X 9s. EXIST. SPOT ELEV. MEET LOCAL AND STATE BUILDING CODE, ALL
j' DWELLING DOORS OPENING TO POOL SHALL BE
ALARMED TO CODE.
--1991 PROPOSED CONTOUR
198.4] PROPOSED SPOT EL. N85"10'¢7" BENCHMARK
WCONC�2ETE BOUND
EL' = 29.6'
T"' '77.21 -- _ SYSTEM DESIGN:
TEST HOLE J �- .
YYY � � , v 1�'-' CB OH FND
2J� LOT 5A W Q GARBAGE DISPOSER IS NOT ALLOWED
SLOPE OF GROUND O p
19,952± S.F. X 10.0'
UTILITY POLE r o -2� DESIGN FLOW: 4 BEDROOMS ® 110 GPD = 4_40 GPD
H 9�F o 10 ✓APArrESf 0 USE A 440 GPD DESIGN FLOW
FIRE HYDRANT o MAPLE
NOTE NOT ALL SYMBOLS MAY APPEAR IN DRANANG TH1 SEPTIC TANK: 440 GPD (2) = 880
11 1
TH2 \1 _R T I{ � USE EXISTING 1000 GAL. SEPTIC TANK
O `\ I jri�V LLI /I J
LEACHING:
TEST HOLE LOGS o ��: % ,' , ;r � Lo
}}
o �:J r` r i� N SIDES: 2 42.0 + 12.831 2 ((.74 = 162.2 GPD
o 1! !r ra r -- L i )
ENGINEER:.DANIEL E. GONSALVES, SE #13587 I►--,-3� (` 16.5' PROPOSED , , r �, ;r cn BOTTOM 42.0 x 12.83 (.74) = 397.8 GPD
DAVI D STANTON, RS / 36' x 18 rj ,1 r INV. OUT -
WITNESS: _ _- ___ -_ EXISTING DECK POOL r, 'r r1 vrr 28.0± o TOTAL: 757 S.F. 560 GPD
DATE: 1 1/5/19_--- -- `` DWELLING 1 �, r'` r! r 16`:9' O
-_._
TOF=30.5 ------ r rr ' I E (4) 5 LEACHING CHAMBERS (ACME OR EQUAL)
1 USE
0S0T GAL.
PERC. RATE _ < 5 MIN INCH 4.0' 0 ALL AROUND
CLASS ___ _- SOILS
P 19-190 "� i POND rr i i ,
I _,,I( `C1,l 1' 1' , i O 'I PROPOSED
�'-, _ `
ELEV. ELEV.� _ �._ SHED WITH
CONVENIENCE
0 4 0„ 4 28.9'_ _ a + L - J �.7�°y ,.
29 0' PATIO (BELOW')' ,\ BATHROOM
GARAGE o z ✓APANESL- APPROVED DATE BOARD OF HEALTH
fS
LS LS `�Afl_Wlk SLAB=29.6 czv3L)"'qAK.30" OAK f.
TITLE 5 SITE PLAN
10YR 4/3 10YR 4/3 1>
12" 14 ���9 OF
B B
LS LS CB DH FND #58 HOLLINGSWORTH ROAD
„ 1OYR 6/6 10YR 6/6 �, S88-18'33"W iI 170.53' - OSTERVILLE, MA
28 26.7 26pt 26.7 --- y�
PREPARED FOR
�HaF�r�ss MATT HAVERKAMP
c c ,�� oANIEL �, ,� ��.
PERC j= A. �t DANiELA. yG�
OJALA u a OJALA
ZONING SUMMARY ; v No 40980 {, ►VIL v
DATE: NOVEMBER 11, 2019
M/FS M/FS �c�t s5\01�y �No.465024 - DATE: NOVEMBER 20, 2019 (SAS)
ZONING DISTRICT: RC RESIDENTIAL DISTRICT `�NOSUFts��°� ��F�orsle�'``�a�' DATE: NOVEMBER 25, 2019 (SAS DETAIL)
SSrONAL DATE: APRIL 14, 2020 (SHED)
2.5Y 7/4 2.5Y 7/4 MIN. LOT SIZE 43,560 S.F.
MIN. LOT FRONTAGE 20' ( off 508-362-4541
tax 508-362-9880
2
MIN. LOT WIDTH 100' downcope.com O
MIN. FRONT SETBACK 20' 11
MIN. SIDE SETBACK 10' down efpe eft INering, toe.
126" 18.5' 126" 18.4' MIN. REAR SETBACK 10'
DATE DANIEL A. OJALA, P.E., P.L.S. civil engineers
NO GROUNDWATER ENCOUNTERED MAX. BUILDING HEIGHT 30' Scale: 1"= 20' land Surveyors
939 Main Street ( R to 6A)
DCE # 19-369
av 50 FEET YARMOUTHPORT MA 02675
19-369 10-25-19.DWG