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HomeMy WebLinkAbout0014 ICE VALLEY ROAD - Health Ic VeIf�y Road Osterville = 119 080 ° ` a o ` c , a r t 0 a ° a L x , z 0 I � ; No. Fee n THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: J� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes I 4`� 2pplication for Disposal O stem (Construction 3Pffmit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) �J Complete System ❑Individual Components Location Ajdre&s or Lot No. / e 4f 11A bey O e 's Name,Address d Tel.No. so � � 1 / sp 4� G CUO Asses or's p arce _ ( e I )1 s,Aiam dres el.No,— D -30�f�/ Designer's N e,Address,an el:j�TJS i �GAVSt7p' G iDa1 .��liC IVi�I� to#stT u6:eer �(/ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.require ) I gpd Design flow provided gpd Plan Date Number of sheets J Revision Date Title Size of Septic Tank ©6® Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code d not to ace the system in operation until a Certificate of Compliance has been issued by this Boar ealth. i ed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued _ . ----------------------- - -__- � � JNo. Fee PTHE COMMONWEALTH OF MASSACHUSETTS Entered,in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ,.. „ Application for Disposal lip construction hermit 4Z. .st trt Application for a Permit to Construct( ) Repair( Upgrade( )` Abandon( ) Complete System ❑Individual Components *' Location Address or Lot No. c e A �/ Owner's Name,Address,and Tel.No. 'i fa AssesSof's�vldp/P'ai'ce1 t 7Z 1 --,119 1 Installe'}'s�1ame�A,.�ddressg,�e�nnd Tel.No._.,,_ _6 -�U� 0/ � Designer's Name,Address,ands el No � ' i �l1 6�57JvvG� ,a,�! �LA:IC, C-C.r Type of Building: ( u j Dwelling No.of Bedrooms Lot Size L sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons J Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) J i7 gpd Design flow provided ✓ gpd Plan Date j.A Number of sheets Revision Date y M Title Size of Septic Tank %nnn Type of S.A.S. Description of Soil I •, f' ' Nature of Repairs or Alterations(Answer when applicable) 'y 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 d not to lace the system in operation until a Certificate of Compliance has been issued by this Board of-Flealth. 14 i ed _ Date ' ' Application Approved by J �/� Date v o' Application Disapproved by Ar ✓/ Date I for the following reasons 1 . Permit No. Date Issued t/ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed(X� Repaired( ) r Upgraded( ` ) Abandoned( )by J at has been constructed in rd.?e: with the provisioons ofTitlee 5 and thefr DisposalZ'o stem Construction Permit No. ✓ � / � Gt Installer �y� l7 f D� .i C A-) Designer r!-14 c t_4 ! ; #bedrooms— TP�J J Approved desig ow J gpd The issuance of this permit sha 4 not be construed as a guarantee that the system will fi ciii esigned. Date ll Inspector 4 ` ---------- --- - - ----- -------------------------------------------------- ----------------------------------------------------- . No. FeeTHE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit 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 a com>4eted within three years of the date of this permit. Date / Z�t Approved by T d ff I Town.of Barnstable Inspectional Services zanrrsrn= 1 Public I ,tlth Division 6'o � Thomas McKean,Director p�a �r► 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 4 3 U1 4 Sewage Permit# Assessor's Map\Parce1 J g0 Designer: fuy 5��.at (Va ; Installer: 0 -'-► Address: 2,66 (Agy.gEl'L,�'' tG�,�t„1+► Address: On was issued a permit to install a (date) (installer) septic system at �fi!'i AVIk TtA� based on a design drawn by (address) dN�.1 �Ch�111►��l�G dated lZ •e5•.Zo t / (designer) t y I certify that the septics stem referenced above was installed substantially according to the design, which ay include minor approved changes such as lateral relocation of the distribution box and/or septic tank: Strip out ' ) was inspected and the soils were found satisfactory. 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 as-built by designer to follow. Strip out (if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in compliance with the to rms of ap oval left rs applicable) 9C HN G. yZ� 1 a a, SCHNAIDCE No 1017` r ( si er s ig (AIffixDesftfi Here) i , PLEASE RN 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. \\Loa\depts\HEALTMSEWER connecASEPTIC1Designer Certification Form Rev 8.14-13.DOC AWC Guide to Wood Construction in High Wind Areas: 110 mph Wind Zone Massachusetts Checklist for Compliance (7go CMa 5301.2.1.1)1 -WHEN THIS EDGE R MIS ON FRAMING US£Sd NA" A7 6'o c. ___.-�_fr 1'! 11 11 1/ 11 11 1 11 11 1 Y 1-1 it ,1 11 1 11 1 11 11 li I 11 11 I 71 11 11 i 11 11 6Y _ IICC 11 I t - i 1{ Y 1 1 1 1 r 1 11 ii, 1 m 1 1 co w n i t n1 I f 1 Ir � /1 11 11 . Ir OQ fJ Ir 1 � Sr 1d I! 11 II lu 1 II a ii IF W 1 11 V 11 11 f' ! u r • 1 � II t1 11 ' I I I-fly••••__ IJOILIE EDGE MILSPACING �I i PANEL See Detail on Next Page Vertical and Horizontal Nailing for Panel Attachment I AWC Guide to Wood Construction in High Wind Areas: 110 mph Wind Zone Massachusetts Checklist for Compliance (780'CMR 5301.2.1.1)1 a 6Z: I ti m FRAMING MEMBER$ i EDGE ROBWEDIATE � Z STAGGERED NAIL PATTERN PANEL i1l PANEL EDGE DOUBLE NAIL EDGE SPAC&IG WrAL Detail Vertical and Horizontal Nailing for Panel Attachment 14 Ice Valley Road: C)stervil e, &I N L.ow er Level Floor Pl`ar ! 3 4'x 4 � � - Game - iTtility. Room Room' 22'X1t ' 14 X1 E FP Store-- Media T- 14`x�o' Y, Room _.... _. 26,xl5l. Utility, ' € Area.. � iQr X4' i _ u W: z x -TYPICAL CONNECT tOKBETWEEK NEW AND OLD WALLS: f ui o 14 �J reemaa•c�vana+ AfASTER;pNTE J. 1 4fhSf+dT ii1C�' iF{ . 3�' � mua•.am FOUNDATION 1 i NEW FOUNDATION PLAN FLAN; --- _-. _ _.. 5 . w _.._ A7 i I LOCATION C� �C11-- Q I t" NO `� DATE '- APPLICANT �� ��-- �LY��`!�' '-�i ., FEE j ADDRESS r , _2Q Non-refundablc o ( ,i1 � - TELEPHONE N0. ,ENGINEER" �, , TELEPHONE NO DATE SCHEDULED V.;�_A, ( 10"Sal-v1 (Applicant' s signature ASSESSOR'S MAP & LOT N0. p I , (, SOIL -LOG ' SUB-DIVISION NAME C DATES TIME A"t:- EXPANSION AREA: YES__K NO ' .•• Alye .pc- ENGINEER TQWN WATER PRIVATE WELL .r. BOARD OF HEALi ! 0 EXCAVATOR SKETCH: ,(Stzeet name, etc. ,dimensions of lot, a ct location of test holes and ..,'percolation tests, locate wetlands in proximity . to test holes) % NOTES : �/k � _ . US ti V. z�s►81 y 7� r •f .�. , 7 1 • �. AA . k" PERCOLATION RATE: L-Z- t Fc6L IIUG I* TEST HOLE NO: 1_�k- I ELEVATION: TEST HOLE NO: ELEVATION: • 1 I�a�n1�Sue��� 1 2 2 Un^tA 3 3 • 4 4 5 5 KEG . •. ., 6 L 6 , 8 8 • 10". �0 10 12 ,_ Vjg-k&t 12 13 ' 13 14 14 15 15 16 1:-.•:. . 16 SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD & LEACHING PITS • LEACHING TRENCHES UNSUITABLE POR SUBSURFACE SEWAGE. REASONS -,, JAI•E� _ NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ORIGINAL: COMPLETED TN ENTTRETY 1Y P . E , AND RETURNED TO BOARD OF HEALTH, COPY: RETAINED' BY APPLICANT v No.. .._. ( Fps.. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH %o.w.�✓.................OF..........1.04001/1��5'.TA/3L,E----------------------------- Alipfiratiuu for Elhgpaal Works Tonstrurtinu rruti# Application is hereby made for a Permit to Construct (✓f or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot ....T_A.__t_..N 01V......4rY.s�d .............................•.... Q`'T ���i .......} �_..------....�.-d....�...........-----...-- Own J_.."... �G.7��7 e � .[Ic••�- f �! �T�6�re s I'`/!f.J/! ��f Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.......-j.................... .....Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons..................._........ Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................ W Design Flow..........11 ........................gallons per person per day. Total dajlyhow........cs6O.......... ............gall--ons. R: Septic Tank—Liquid capacity/A�_.gallons Length./Q.-_..... Width.�X-- Y.... Diameter................ Depth6�._ ..... Disposal Trench—No. ................... Width.................... Total Length........`..�� Total leaching area___.....-'-_/-._.._...sq. ft. 3 Seepage Pit No......0-Z---____-_ iameter.......6........ Depth below inlet......?`-_...._.. Total leaching area4W.7.9.._sq. ft. z Other Distribution box (� Dosing tank ( ) q / ~' Percolation Test Results Performed by­elf f L'/��.s... _ ....................... Date....!_._..3."��?-_......._... aTest Pit No. 1......?--___.minutes per inch Depth of Test Pit.4................. Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 --••••-----•---•..................•-•---............_._...•••-•••••-•••...._.........--------................................................................ 0 Description of Soil... --------- -------••-•----•-•--•---------------------------------•------............................................................ U W -----------------------------------------------------------------------------------------------------•--------------------------------------------...-----•---------------------------...._.......-•-- U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------________--____-___-__--__-_____--_-_--. --------•--•--------------------------------------------------------------------------------------•----------------------------------------------------•------------•-------------------..........---•.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of I-- p of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en issu d by the b rd f liealth. Si ned --- 1 a•- Date Application Approved By....... ----. ---- •--•••-- --•---------------------------------•-- Date Application Disapproved for the following reasons:----•---------••----••-•---••--•----•-------------------------•----------------------------------•••-........... --------------------•------------•----•-••---•---------------.....-•-------------•---------•--------...---•----••----•••-•--••--- -----------------------------------------.................... Date ,- 2 i Permit No......... ... - Issued.......................................... Date No........................ FEs............._....._......_ THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH ...... ........I.....OF............ ................ Appliration for Uh4posal Works Tonstrurtion Prrutit Application is hereby made for a Permit to Construct or Repair ) an Individual Sewage Disposal System at: vat ...................... .................. .......................................... Loc,_�,Ion-Address or Lot o.........................COW-97"---------------- ......................................... Owner _40 V ... _t ...... .................... ... A ss Ins'ller Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.__1_-1111'.:r_111111-------------­-Expansion Attic Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ........................................................................................................... < --------------*-------------- ------- Design Flow...........//0.......................gallons per person per day. Total daily flow-_-_--_ .....................gallons. 1:4 Septic Tank—Liquid capacity/OV. ..gallons Length../Z Q....... Width.Xy.. Diameter................ Depth. Disposal Trench—No_____________________ Width..... Total Length...... . ;;------------- )p--- Total leaching area......... sq. ft Seepage Pit No.......2----------- Diameter..___..._._..._. Depth below inlet.....-______ Total leaching area.ia�i/_'_ q ft. Z Other Distribution box (u-j Dosin t nk ( ) Percolation Test Results Performed by__.XW/_m'e..A-. *V 4e Date....9-3--Aa............ * ..../ -----------------------­ .......... Test Pit No. I......4-----minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..____._............__.. P4 ............................................................................................................................................................. 0 Description of Soil.......................................... ............................*-------------------------------------------­----------------------------------------------- �4 - U .................................... ........................................................................................................................... .....................................................................................................................w.................................................................................. U Nature of Repairs or Alterations—Answer when applicable-----_------------_--------............................................................ ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TT"_ 4 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en issued y the oeard le e.. r7 Signe ......ke'_' .......................... .. .... Date Application Approved By......:77772��/........... ......... ........................................... ........................................ Date Application Disapproved for the following reasons:.............................................................................................................. ......................................................................................................................................................................................................... Date Permit No..........`�i;_77---------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS : OARD OF HEALTH ........... .... J, OF................. ...... .................................. TwWrtifiratr of Toutpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ---------- .by....................... ......... ---------Installer----------------------------------------------------------------------------------------------- at......... .... I IP-;-' 19.....�.c JC4,\ ----- —----- ------------------------------------------------------ ---------------------*' ...... . . , has been instilled in accordance with the provisions oUrITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. _1774=_12.+1- ----- dated-------------C/ Z %7... ---/._D�AT THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE T A YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................... ..................... Inspector... ............................. �7 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............OF...........0 .............................................. 21...... - Dispoal Yorks Tallustrurtivit "Prrutit Permission is hereby granted............ . I ' , - _­�r---IC-3 .......L-) -------------------------------------------------------------------- to Construct or Repair an Individual Sewage Disposal System atNo......L.z?..J------- .............. ........... ....................................................... Street as shown on the application for Disposal Works Construction Per VA* zX&_2.-.?_.!.5._..... Dated..... DATE._.... ........................................... ..... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS Jun '24 2019 07:17 HP Fax page 19 9- 600 Commonwealth of Massachusetts Title 5 Official Inspection Form ' x- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valley Road `lam Property Address ri«+ Thomas Nelson Owner Owners Name R information is required for every Osterville ✓ MA 02655 6-21-19 ;i t= page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information �/� (S 9(B ,,���• s��'°, filling out forms y a on the computer, � :' JAM G use only the tab James D.Sears = E S m i key to move your Name of Inspector 5EARS cocursor-do not Ca ewide Enterprises # use the return Company Name ��' key. 153 Commercial Street o 5lN8PE�'�````'` Company Address e �1� Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 Cli 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training-and.:experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2_ ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 6-21 19 " L4,10ector'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 has a design flow of 10.000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of Inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.00c-rev.7/26/201 a Tde 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 o11 a ' Jun '24 2019 07:17 HP Fax page 20 Commonwealth of Massachusetts TU Title 5 Official Inspection Form Ic Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name information is required for every Osterville MA 02655 6-21-19 page. City(Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.. Comments: The systen is a 1500 Gal.Tank 0 Box and two pits, 2) 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. 0 Y ❑ N ❑ ND (Explain below), t' t5insp.doc rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 I Jun '24 2019 07:17 HP Fax page 21 Commonwealth of Massachusetts �.�ulv Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valley Road ` Property Address Thomas Nelson Owner Owners Name information is required for every Osterville MA 02655 6-21-19 page. Cityfrown State tip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. Systern will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): , . ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.3030)(b)that the system is not functioning In a mannerwhich will protect public health, safety and the environment: 15insp.doc rev.7/25=1 6 Me 5 Official Inspection Form:subsurface sewage Clsposal System•Page 3 of i 5 Jun '24 2019 07:18 HP Fax page 22 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valle y Road Property Address Thomas Nelson Owner Owner's Name ieon Is required forevery Osterville MA 02655 6-21-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cons) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within t 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 if th system asses Y p e well water analyses, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Lsinsp,doc-rev.7126/2019 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 16 Jun '24 2019 07:18 HP Fax page 23 Commonwealth of Massachusetts 6P Title 5 official Inspection Form ,li Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valley Road ' Property Address Thomas Nelson Owner Owner's Name equir ati fo is every required fo psterville MA 02655 6-21-19 r page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary(cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in 111kIM is less than 6"below invert or available volume is less than %day flow PIT ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within,a Zone 1 of a public water supply well. ❑ ® Any portion of a-cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered,A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have,determined that one or more of the above failure criteria exist as described in 310 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection Area—IW PA)or a mapped Zone II of a public water supply well t5insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 19 Jun '24 2019 07:18 HP Fax page 24 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f" 14 Ice Valley Road Property Address Thomas Nelson Owner Owners Name information is required forevery Osterville MA 02665 6-21-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6• You must indicate"yes"or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ 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: E ❑ 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)) I5insp.doc•rev.7126(2018 Title 5 Official Inspecuan Form:Subsurface Sewage Disposal System•Page 6 of 18 f ' Jun '24 2019 07:18 HP Fax page 25 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Ice Valley Road Property Address Thomas Nelson .. Owner Owner's Name information is required for every Osterville MA 02655 5-21-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 Description: 1500 Gal, Tank D Box and two pit's. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report,) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2017-65,000Gals g ( y ge{gpd}): 2018-250,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date t5insp.doc-rev.712612018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 7 of 18 r Jun 24 2019 07:18 HP Fax page 26, Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage disposal System Form,-Not for Voluntary Assessments 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name information is required for every OSterVllle MA 02655 6-21-19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. CommerciallIndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3, Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.tloc•rev.7/26/2018 Title 5 Official insQection Form;Subsurface Sewage Disposal System•Page 8 of 18 Jun 24 2019 07:19 HP Fax page 27 Commonwealth of Massachusetts Title 5 official Inspection Form 11. r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Ice Valley Road Properly Address Thomas Nelson Owner Owner's Name information IS required for every Osterville MA 02655 6-21-19 page, cityrrown State Zip Code Dale of Inspecdon D. System Information (cons) 4. Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes,attach previous inspection records, if any) ❑ Innovative/Altemative 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 contrail ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed(if known)and source of information: 1987 Permit # 87-215. 6-2019 New D Box, Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 22' 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.): Pipeing is 4" PVC SCH -40. t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Jun 24 2019 07:19 HP Fax page 28 Commonwealth of Massachusetts Title 5 Official Inspection Form Fla Subsurface Sewage Disposal System Form -Not for Voluntary Assessments S 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name information is required for every Osterville MA 02655 6-21-19 page. City/Town State Zip Code Date of Inspection D. System Information (cons.) 6. Septic Tank(locate on site plan): 1 Depth below grade: feet Material of construction: ® concrete ❑ metal _ ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal,list age: years . it Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-10 Sludge depth: 2" Distance from top of.sludge to bottom of outlet tee or baffle 28 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-TapeSludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,,evidence of leakage, etc.): Tank at working level. Tank and covers at l'below grade. Inlet tee w/outlet baffle, No sign of leakage or over loading. Note: Maint. Pump after inspection. t5insp.doc•rev.7/2 6120 1 0 Title 5 Official Inspection Farm Subsurface Sewage Disposal System Page 10 of 18 r Jun '24 2019 07:19 HP Fax page 29 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name information is required for every Osterville MA} 02655 6-21-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: reel Material of construction: ° ❑ concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: _ Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): , Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2012018 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of to r Jun '24 2019 07:19 HP Fax page 30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valley Road Property Address Thomas Nelson Owner Owners Name informrequired Osterville MA 02655 6-21-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): a Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locale on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D Box is 16"xl6"-18"below grade w/two lines out. Box is New 6-2019 w/cover at 6" r I t51nsp.doc-rev.7/26/2018 Title 5 OBidal Inspection Form:Subsurface Sewage Disposal Sysmm•Page 12 or 18 Jun '24 2019 07:19 HP Fax page 31 Commonwealth of Massachusetts P Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y� 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name information is every Osteryllle required for eve MA 02655 6-21-19 page. City/Town State Zip Code -Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: . ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: D overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 15insp.doc-rev.7/2 5120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Clsaosal System•Page 13 of 18 Jun 24 2019 07:19 HP Fax page 32 Commonwealth of Massachusetts va Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments � 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name information is required for every Osterville MA 02655 6-21-19 page, Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 11, Soil Absorption System(SAS)(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two pits .Pit's have 20"water w/no high stain Iine.No sign of over loading or solid carry over. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): 4 15tnap.doc• t v.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 10 Jun '24 2019 07:19 HP Fax page 33 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name required on is Osterville MA 02655 6-21-19 required for every page. CitylTovm State Zlp Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I Iftsp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 I - Jun 24 2019 07,19 HP Fax page 34 Commonwealth of Massachusetts Title 5 Official Inspection Form p Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name -- -- -- information isOsterville MA 02655 6-21-19 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (coot) 14, Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below, ® hand-sketch in the area below ❑ drawing attached separately p _ O I � O je = 4 a 15` l6-a , '�3� /�-3 /q r13�� 13 39' Mnsp.doc-rev.7/261201 B Title 5 O%al Inspection Form:Subsurface sewage Oisposal System•Page 16 of 1s a Jun* 24 2019 07:20 HP Fax page 35 . Commonwealth of Massachusetts Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name Informrequired tion s Osterville MA 02655 6-21-19 required for every page. CitylTcwn State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 14' 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: Abutting property and T.H. 14' no G.W,. Bottom of pit at 10' below grade. Bottom of pit at 4'above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t6insp.doc•.rev.V2812018 Title 5 Orfidal Inspection Form:Subsurface Sewage Disposal System•Page 17 at 18 IJun"24 2019 07:20 HP Fax page 36 Commonwealth of Massachusetts SO Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name Informrequired s Osterville MA 02655 6-21-19 required for every page. CityfTown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section: ® B.Certification:.Signed &Dated and 1, 2,,3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included is R AD f 'f 6 Aim No G.w t5insp.doc•rev.712 612 01 8 The 5 Official Inspection Form:Subsurface Sewage Olsposal System•Page 18 of 18 No. 0-V l / v Fee `7_ % / THE COMMONWEALTH.OF MASSACHUSETTS Entered in computer: �/��( Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication f 0 igPOgar *pgtem congtruction vermit Application for a Permit to Construct(.% )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or LotNo Y � �1�-ti/ Owner's Name,Address and Tel.No. Assessor's Map/Pa►telpG /I1� / v� Installer's Name,Address,01" d Tel. � j,OGT7 V Designer's Name,Address and Tel.No. IVY p, 1 td�8 /" Type of Building:(3 IV — b/ Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) JL�— Date last inspected: Agreement: . The undersigned agrees to ensure the construct'o aintenance 4 t afore described on-site sewage disposal system in accordance with the provisio o Title 5 of r in ntal C e a p a stem in operation unt' a rtifi- cate of Compliance has bee issued by t ' o ,lz- Sign Date Application Approved by Date Application Disapproved for the following reasons Permit No: Q �s Date Issued l ---� — --------•-------- `-�� / � �G � � Fee �f ,d I� No. � ✓Ir !( THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS ZIppYication fo tgpoga[ *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( ,,)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. G f �,n 1 1_ Owner's Name,Address and Tel.No' Assessor's Map/Parllel� (/�! (/Ti ! ` ' j Installer's Name,Address,and Tel.No. VG `, Designer's Name,Address and Tel.No. ft Al ILLS pl /4 t Type of Building:, ) L)�? -_5(9 - 01 r Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) r !Otfier Fixture& Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil � Nature of Repairs or Alterations(Answer when applicable) Date3last inspected: Agreement: The undersigned agrees to ensure the construct'o rand maintenance of the afore described on-site sewage disposal system ` in accordance with the provisior��r6f le 55 nv?onmental Code a i�o pC -Tacc thesystem in operation unti Zrt/ ifi- cate of Compliance has bee (issued by th' and o //Signe Date to Application Approved by . fir. ✓ Date Application Disapproved for�theyfollowing reasons_ .,. Permit No. O r �� 5� Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( Repaired( )Upgraded( ) Abandoned( )by at L 1, ,has been constructed in.Accordance with the provisions of Title 5 and the for Disposal System Constructiop Permit No. �Y9 5 dated to A//q Installer r1 1/ / A/0lr (IL. lsrgner The issuance of s p rmit shall not be construed as a guarantee that the sy e7, 111 function as des' ed. Date o Inspector ' v 77 f — No. 5�-�L! o� �S ` ' Fee THE COMMONWEALTH OF MASSACHUSETTS _.S PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS w5pow", potem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at r- t;­ V A_ I y_ &c7�) 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 o(fff`i pe Date: tt7 f ( t { Approved by\ 1 /H_ 096 Commonwealth of Massachusetts Title 5 Official Inspection Form, ° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t� 14 Ice Valley Road '' Property Address , Thomas Nelson x_ Owner Owner's Name information is required for every Osterville V MA 02655 6-3-19 w_, page. City/Town h State Zip Code Date of Inspection t� 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. ``,tlflkpinF'I."y7j fmngoutf forms A. Inspector Information ,�`� rilli out forms �,�•. ' use onlon the y theJames D.Sears ��g�' JAMES key to move your Name of Inspector = ; .-, cursor-do no: Capewide Enterprises use the return Company Name �• o TtF O �� key. '�sy 153 Commercial Street y%,,,3 INSpE„``��`� Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑ Passes u 2. ® Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails St3" 6-6-19 Wspector'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 has a design flow of 10,000 gpd or greater; the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 15insp.doc-rev.7126/2018 Title 8 Of@dal InspeCbon Form:Subsurface Sewage Disposal System•Page 1 of 18 L£ a5ed xeJ dH ZO:LO 61,0Z LO unf Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name information is Osterville required for every MA 02655 6-3-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. - Comments: Conn Pass-D Box. The system is a 1500 Gal.Tank D Box and two pits - 4 2) System Co nditionally n all Passe s: ❑ 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 exfiltraiion or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc rev.7126/2018 Tdle 5 Dfhclal Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 g� a6ed xeJ dH F0:L0 WE LO unr Commonwealth of Massachusetts Title 5 Official Inspection Form " 1,tvw�6 r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name Information is required for every Osterville MA 02655 6-3-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): Need to replace D Box. ' ❑ 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 ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7126/2018 Tllle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 66 a5ed x2J dH EULO 61.0Z LO unr. 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valley Road . Property Address Thomas Nelson Owner Owner's Name information is required for every Osterville MA 02655 6-3-19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cunt.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 Feet of a surface water supply or tributary to a surface water supply. , ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well`*. Method used to determine distance: r ' This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: , 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 15insp.doc-rev.7/28/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 OV a5ed xe i dH £O;LO 660Z LO unr Commonwealth of Massachusetts Title 5 Official Inspection Form' +# Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valley Road Property Address ' Thomas Nelson Owner Owners Name information is Osterville MA 02655 6-3-19 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet.invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in mmsspoW is less then 6" below invert or available volume is less than 1/2 day flow s0/Ts ❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy,is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5mp.doc-rev.7/26=18 Tale 5 Official Inspection form:Subsurface Sewage Dispose System•Page 5 of 18 6,V a6ed xed dH tiO:LO 61,2 LO unr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valley Road Property Address Thomas Nelson Groner Owner's Name required information is Osterville MA 02655 6-3-19 required for every page. CitylTown State Zip Code Date of.lnspection C. Inspection Summary (Cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of.the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El ® 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. Ei ® 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)] 15insp.doc•rev.7J,2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Zb abed xed dH VUL0 660Z LO unf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments k.Vw� v-a s 14 Ice Valley Road `J PropetyAddress Thomas Nelson Owner Owner's Name information is required for every OSterville MA 02655 6-3-19 per, City/Tom State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 Description: 1500 Gal. Tank D. Box and two pit's. � I 2 Number of current residents: k Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? - ❑ Yes ® No Seasonaluse? ❑ Yes ® No 2017-65,O0013als - Water meter readings,if available(last 2 years usage(gpd)): 2018-250,OOOGal's Detail: Sump pump? ❑ Yes ® No Present Last date of occupancy: Date t5insp.doc-rev.712&2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 7 of 18 £� abed xed dH tO:LO 660E LO unr Commonwealth of Massachusetts r Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 14 Ice Valley Road Property Address - Thomas Nelson Owner Owner's Name information is required for every Osterville MA 02655 6-3-19 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): canons per day(9pd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15insp.doc•rev.7/26/2018 Title 6 Of vial Inspection Form:Subsurface Sewage Disposal System-Pdge 8 of 18 �� a5ed xe� dH 50:LO 61.OZ LO unr Commonwealth of Massachusetts ,p Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name information is required for every Osterville MA 02655 6-3-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: } ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1987 Permit # 87-215. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 22' 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.): Pipeing is 4"PVC SCH-40. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 or 18 gb abed xed dH 90:LO 660Z L0 unr Commonwealth of Massachusetts Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name information is required for every Osterville MA 02655 6-3-19 per. City(rown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1r 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 ElNo Dimensions: 1500 Gal. Precast H-10 Sludge depth: 2' Distance from top of sludge to bottom of outlet tee or baffile 28' Scum thickness lip Distance from top of scum to top of outlet tee or baffle 1211 Distance from bottom of scum to bottom of outlet tee or baffle 17 How were dimensions determined? Asbuilt-TapeSludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tank at working level. Tank and covers at 1'below grade. Inlet tee w/outlet baffle. No sign of leakage or over loading. Note: Maint. Pump after inspection. 15insp.00c•rev.NE12018 Title 5 Offic al Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 9� a5ed xe� dH SOLO 660Z LO Of Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 14 Ice Valley Road V Property Address Thomas Nelson Owner Owner's Name requinform r don is for every Csterville MA 02655 6-3-19 required page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: t ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete •❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp,doc-rev.T12812018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 11 of 18 Lb abed xe� dH 5ULO 660Z LO unr Commonwealth of Massachusetts Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name information is Osterville MA 02655 6- -1 required for eve 3 9 eU every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-18" below grade w/two lines out. Wall's are gone on box. Need to replace D Box. t5insp.doc-rev.7126/2018 Title 5 Oftal Inspection Form;Subsurface Sewage lJisposal System•Page 12 of 18 g� a6ed xed dH 9010 610Z LO unr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments i 9 P Y rY , PIP;` 14 Ice Valley Road �v Property Address Thomas Nelson Owner Owner's Name information is required for every Osterville MA 02655 6-3-19 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No` Comments (note condition of pump chamber,condition of pumps and appurtenances, etc.): ` If pumps or alarms are not In working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology; t5insp.doc rev.1/26/2018 Title 5 official Impedion Form:Subsurface Sewage Disposal System-Page 13 of 18 61v a6ed xed dH g0:L0 61.0Z LO unf R Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valley Road Property ert Address Thomas Nelson Owner Owner's Name information is required for every Osterville MA 02655 6-3-19 page. City/To" State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Leaching is two pits. Pit's have 20"water w/no high stain line. No sign of over loading or solid carry over. 12, Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer - Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of,ponding,condition of vegetation, etc.): t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page f 4 of 16 0g abed xeJ dH 90:L0 61,02 LO unf Commonwealth of Massachusetts ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v, 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name information Is required for every Osterville MA 02655 6-3-19 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 15insp.doc-rev.7012018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 18 65 abed xed dH 90:LO 61.0Z LO unF Commonwealth of Massachusetts Title 5 Official Inspection Form Vel Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 14 Ice Valley Road Property Address , Thomas Nelson Owner Owners Name Information is required for every Osterville MA 02655 6=3-19 page. City/Tovm State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including lies 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 o t 4 ,a-a r' -3 -a` f4 N A.s-: s3 15insp.doc-.rev.M612018 Title 5 Ofiasl Inspection Form:Subsurface Sewage Disposal System-Page 15 of to Z5 abed xed dH 90:L0 660Z LO ucf Commonwealth of Massachusetts Title 5 Official Inspection-Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name information is Lvo required for every Osterville MA 02655 6-3-19 page. City/Town State Zip Code Data of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 14' Estimated depth t high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked 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: Abutting property and T.H. 14' no G.W.. Bottom of pit at 10' below grade. Bottom of pit at 4'above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Mnsp.0oc rev.7126/2018 Title 5 otrtcial Inspection Form:Subsurface Sewage Disposal System-Page 17 011.8 £5 a6ed xeJ dH LO:LO 61.OZ LO unr 6 Commonwealth of Massachusetts Title 5 official Inspection Form �o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 14 Ice Valley Road Property Address Thomas Nelson Owner Owner's Name information is required for every Osterville MA 02655 6-3.19 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed &Dated and 1, 2, 3, or l4 checked ® C. Inspection Summary: 1,2, 3, or 5 completed as appropriate 4(Failure Criteria)arid-6 (Checklist)completed ❑ D. System Information: For 8: Tight/Holding Tank- Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg• 16 or attached For 15: Explanation of estimated depth to high groundwater included Glla . n)r No Ilf t5insp.doc•rev.7l2612018 Title 5 OfBcial Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 b5 a6ed xed dH LULO 61,N LO UK Massachusetts Department of Environmental Management 0 S o o Office of Water Resources v TYPE OR PRINT ONLY Well Completion Report 1.'WELLLOCATION ,G''P//S (OPTIONAL) LA"TITUD_E � � � LONGITUDE Address at Well Location 1 Y f� '�t �y. Property Owner: � Al Subdivision Name: Mailing Address:. ,v 60 City/Town: (9Z7-i5'V i J-.L-E City/Town: Assessors Map Assessors Lot#:G NOTE: Assessors Map and Lot# mandatory if no street-address-available Board of,Health permit obtained:- Yes 8�5­ Not°Required ❑ Permit NumberWQOal- Date.Issued'//a6-01 2.WORK PERFORMED 3. PROPOSED USE, , 4:DRILLING' IETHOD-f New Well ❑ Abandon ❑ Domestic 'Irrigation ❑ Cable `Auger ❑ Deepen ❑ Recondition ❑ Monitoring ❑ Municipal ❑ Air Hammer`°;❑' Direct Push ❑ 'Replace ❑ Other ❑ Industrial ❑ Other ❑ Mud�Rota ,❑ Other 5. WELL LOG Cc Unconsolidated Consolidated 6.SITE�SKETCH{Us*p"ar7pnt,1andnlarks with distances) W Permeability H T91-) a> >From (ft) To (ft) > High Low m Other Rock Type ` O, w . �_._... .. _ . ... _ __ _�_ __ _ _ . rd, 160' )40 ti� h)f71 7.WELL CONSTRUCTION 8.CASING. �=' From ft To ft m Casing T� a and Materials Size O.D. in Well Seal T e. Total Depth Drilled O O 9 YP .r ( ). YP :i Date Drilling Complete '���� !l� O lave- -0 9. SCREEN From (ft) To (ft) Slot Size- Screen Type and Material Screen Diameter / /3a ' 10. FILTER PACK/GROUT/ABANDONMENT MATERIAL .. ADD)TIONAL WEI�L INFORMATION Developed? Yes ❑ No . From (ft) To (ft) Material Description�/ Purpose - Fracture Enhancement? .❑ Yes io Method Disinfected? ❑ Yes �,"9No 12.WELL TEST DATA(PRODUCTION WELLS) - - 9O'13. STATIC-,WATER LEVEL(ALL WELLS_) Yield,�eTlme Pumped Drawdown to Time Recovery to Depth Below Date Method (GP,M) `�(hrs,&min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT) 14. PERMANENT PUMP(IF AVAILABLE) -- ¶''tS.NAME)ADDRESS O 'PU1lP INSTALLATION COMPANY Pump Description 6 �� Horsepower Pump Intake Depth h `+ (ft) Nominal Pump Capacity (gpm) 16.COMMENTS 17. WELL DRILLER'S STATEMENT, This well was drilled and/or abandoned under;my supervision, according to applicable rules and regulations,'and this repord'is complete an`d correct to the best of my knowledge. Driller: A �J k-ca �f // r 1 � -71 pervising Driller Signature: ��t'" iti 11,o ttio�_-. Registration #: Firm. EJ tl w,'tC<.� (i()�'1-� i,L°t-.��� /'ilk Date: Z `.3 0�/ Rig Permit#: 7�� NOTE: Well Completion Reports must be filed by the-registered well driller within 30 days of well.completion. ¢ x K:r s 5•:,at puy 4 t. w 3 a x s ,HOARD OF HEALTH COPY 4 � .=. '. 3 , .. -s N e - f s a < - t t 5 _ -t t 1 4 e S S S"* - . . a i c x i f z t♦ i T t.4 r k Y .1 1 t _ . _ .. �+ 5 _ • IIVF RE IE' 2 DEC 00 , s I RNS-rASLE TOWHEALTN DEPT• 1 o � � 1 1 . _ _ ��' � -..— ... ... � —_, r -- ... � a - t .- •y.- ,• _ .. �� � s+ 1. .,� t � t i �g 1 i�� c� ,. _ 4�i`-, .•:rot � ,�,�'a -. a � ;�T� - c• v 1 f fi tl Lev /00 vN • � N 6J ' J v� 57 ` . loS '�q��JILL1Ati7 .�:s 2' ,No. 19334 CE,eT/.c/EO O1�T f�L4�C/ C,6-.27-/.4=Y T,UAT .5`,z10W,41 A/E,eEO.c/COA-1PL YS W171- ANo SETBA Cl.-::: C EQU/,2E�s-1E.c/rS o.�" T.y_,= 7`oWit/DF Lam' �o z C o cA TEr� lW17-111 C/ TyE F.Loar�PG4/y _ 7 ,B,4 XTE.2E A/yE xmc- Ttirs P.c.q vrs ,va7- a,QsEo A(,, AV .eE�isTE.2Eo �.�o SueYEyo� !NS7-.2U�1E�c/l SU,eYE'Y� Th�� OSTE,e1i/,C.,C�v �J,QSS. Al::, -/,,—AIVCc- Z.SSA�+ Y a o 0 j, • 'o i . L/O - /000 -Tow Dog) /A I �U J Ski. kL F F R ' I' �!> Fee-----—`---��-- ---- BOARD OF HEALTH TOWN OF BARNSTABLE 0(ppCicat ion-for lVell Con0ructionpermit Application is hereby made for a permit to Constructer ( ), or Re it ( an individual Well at: Location — Address Assessors Map and Parcel Owner f� Address Installer — Driller Address Type of Building Dwelling ----- ----- ------ Other - Type of Building--- ------ No. of Persons------------_---_ R-k L/ Type of Well ��`r!D�� Capacity`—�-b-= --- Purpose of Well—=L �`' —1 — Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of He th Private Well Protection Regulation — The undersigned further agrees not to place the well in operation unti a Certificate of ompliance has been issued by the Board of Health. �• ! Signed __ — — -�jG-�— da Application Approved B ��A -- PP PP YY, Q 1 �- date Application Disapproved for the following reasons: — — --j— ---- Permit No. "� Q� — Issued----!1�- 2� r, I date --- ---------- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of Compliance i THL5LIST TO CERTIFY, That the Individual We Constructed (a/) tered ( ), or Repaired ( ) ��------------ ----- ----- Installerat has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Frotection Regulation as described in the application for Well Construction Permit No(A P-0—:1 Dated J ia-(,&jO, THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--- Inspector------------------_ — �___ No.�J ------- Fee---------��--------- BOARD OF HEALTH TOWN OF BARNSTABLE 2pprication-for)Dell Cootruct ion Permit Application is hereby made for a permit to Construct , Alter ( ), or Re air ( an individual Well at: Location — Address Assessors Map and Parcel Owner to l,� Address Installer — Driller Address Type of Building Dwelling -_— — - --------- Other - Type of Building-- -----_ No. of Persons-----------------__—__ �l Type of Well T zk I<--1---/ Capacity--�� —t- KT Purpose of Well C - — 00 Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation unti a Certificate.of ompliance has been issued by the Board of Health. C C ! l Signed // a G G datE f . Application Approved By ^ � N` date Application Disapproved for the following reasons: --------- ----- -- r I date Permit No. } Cw` " __ Issued ----- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of (compliance TH IS TO CERTIFY, That the Individual We I Constructed �1, tered ( ), or Repaired ( ) 'by w 6lvQ -- _ Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No.�"-1�C =-��Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL 't SYSTEM WILL FUNCTION SATISFACTORY. DATE--- Inspector---------------- -------- BOARD OF HEALTH TOWN OF BARNSTABLE )Dell (Construct ion permit No. (f ``:/ I Fee--�-/ - Permission is hereby granted ---------- to Construct (. , Alter ( ), or Re air ( ) an Indivi al ell at: Street as shown on the application for a Well Construction Permit' i i1 I J it No.- - Dated DATE Board of Health 1 f 2 �r ���_ —. TOWN OF BBARNSTABLE LOCATION 1'"1 'Ice 19c,Ayj `\u SEWAGE# ,,?ol% YgS VILLAGE ASSESSOR'S MAP&PARCEL ] a INSTALLER'S NAME&PHONE NO. F M &,i f/ SEPTIC TANK CAPACITY %00 LEACHING FACILITY.(type) 9' yd 49 (size) Q X NO.OF BEDROOMS ', OWNER dw PERMIT DATE: tZ 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) Feet Edge of Wetland and Leaching Facil' (If any wet ds exist within 300 feet eaching facili ) Feet FURNISHED �i;c�rc�►�'► d � r� 3A 33 - S6 -3a' yP "' 6 �� JA- iot '3" „,..,�,-,-I.,1”—I,....�o��---,,.-,;I.,..",-I�,�..�,.,I�-.'-,-,��,-�-.��.I�.j-.1:,1,-I,.,.�I.T-I-�I-�i.41,i,.-,7.."�-1I.,,I-�-I,­,���',-­.I----,t,I�I­�j�!.. ,. i .n -• T .f±• t• h "` ` p -. r 1. t.. .. ,':t 'S ,d,. . _ - _�.,. •. _ }ifs 4 J p ( y,`, ram, - - . 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L 24, N Sr }y� V!''� '.-•��� l.Y ���� f ice•- F 9 • ' • '� �� ; l�I, f '. _ s . fir, r. _ ,A r� . y1-t1S, tj lKs s i . . - Sf-kcti ttJ' 'S C - L t, t I T' V CR •I .;,-.-,�': � .,iOI-- . ,... .1 .--, -- � ,., O.----- -�.:-;�!p�---�,�,,--i.(-�"-f�-�t_I I-.,_-t 1,.,, �,"��,,��- ., I . -.., ,t., ,f•-y.,;Fi'f' 3 c �.�'• + i rY4.;.ia."+a,# t' t; +h. �'u:1 , ------------ DEEP OBSERVATION HOLE LOGS PT #19-213 DESIGN CALCULATIONS POTENTIAL 7 BEDROOM DWELLING DATE OF TESTS: DECEMBER 3,2019 DESIGN FLOW- 7 BEDROOMS AT 110 GAL.PER DAY PER BEDROOM=770 GPD -NOW" 7- 770 GPD X 200%=1540 GALLONS-USE 2000 GALLON SEPTIC TANK C 05 PERCOLATION RATE:LESS THAN 2 MINUTES PER INCH DROP IN THE C HORIZON IN DOH#1-DOH#.2 A 85'L.x &W.x 2'D.LEACHING CHAMBER CAN LEACH: WITNESSED BY: JOHN SCHNAIBLE, CEC SE 2166 Vt= 1(86 x 8)+2(85+8)2]0.74= 778.5 GPD DAVID STANTON,HEALTH AGENT COASTAL NO GROUNDWATER ENCOUNTERED LOCUS engineering co. DEEP OBSERVATION HOLE I EL.=52.51 NO SCALE INSTALL: ONE(1 851.x 8 W.x 2'D. LEACHING CHAMBER Vt 778.6 GPD> 770 GPD REQ'D. 260 Cranberry Hwy.Orleans,MA 02653 ONE(1 2000 GAL.SEPTIC TANK 55, SUP 508.255.6700 F ELEVATION DEPTH FROM SOIL SOIL SOIL COLOR SOIL OTHER ONE(I ) -DISTRIBUTION BOX(9 OUTLET) SURFACE HORIZON TEXTURE (MUNSELL) MOTTLING 52.5-51 A 0"-13" A LOAMY SAND 10 YR 3/2 VAL 51.4-48.0 13"-54" B LOAMY SAND 10YR6/6 NOTES FINE TO MEDIUM 1) GARBAGE GRINDERS ARE NOT ALLOWED WITH THIS DESIGN. 48.0-42.5 54"-12V C 10 YR 5/6 LOOSE.5%GRAVEL SAND 2) THE INSTALLER IS RESPONSIBLE FOR ASSURING THAT COMPONENTS OF THE SEWAGE DISPOSAL SYSTEM ARE DESIGNED WITH SUFFICIENT STRENGTH TO SUSTAIN ALL LOADS TO BE IMPOSED ON THEM.ANY DEEP OBSERVATION HOLE 2 EL.=52.7:t COMPONENT OF THE SYSTEM SUBJECT TO VEHICULAR TRAFFIC MUST COMPLY WITH A MINIMUM STANDARD DEPTH FROM SOIL SOIL SOIL COLOR SOIL OF A.A.S.H.T.O.H-20 WHEEL LOADS. BARNSTABLE, MA • ELEVATION OTHER 3) PRIOR TO SETTING ANY SEWAGE DISPOSAL SYSTEM COMPONENT,INSTALLER SHALL VERIFY EXISTING SURFACE HORIZON TEXTURE (MUNSELL) MOTTLING CONDITIONS,INCLUDING ELEVATIONS OF EXIT INVERTS,AND REPORT ANY DISCREPANCIES TO THE DESIGN ENGINEER. 52.7-51.8 (r-11" A LOAMYSAND IOYR3/2 KEY MAP 4) ALL GRAVITY SEWER PIPE SHALL BE 4'DIA.SCH 40 PVC UNLESS OTHERWISE NOTED.THE MINIMUM SLOPE OF 4"DIA.SCH 40 PVC SHALL BE 0.01 FT/FT. NO SCALE 51.8-48.5 11"-50" B LOAMY SAND 10 YR 6/6 5) NO PART OF THIS DESIGN SHALL BE ALTERED WITHOUT PRIOR APPROVAL FROM THE DESIGN ENGINEER AND ASSESSORS MAP 96 THE AGENT OF THE LOCAL BOARD OF HEALTH.ALL REQUESTS FOR CHANGES SHALL BE MADE IN WRITING PARCEL 0041001 FINE TO MEDIUM 48.5-42.7 50"-120" C 10 YR 5/6 LOOSE,5%GRAVEL PRIOR TO CONSTRUCTION. SAND 6) THE USE OF ALTERNATE MANUFACTURERS FOR SYSTEM COMPONENTS SHALL NOT BE APPROVED IF THE USE ROBERT CLAY&LESLEY MAGUIRE TRS : OF THEIR EQUIPMENT REQUIRES CHANGES IN DESIGN. REFERENCE DEEP OBSERVATION HOLE 3 EL. 52.1t NO SCALE 7) THE INSTALLER SHALL ASCERTAIN THE LOCATION OF EXISTING UNDERGROUND UTILITIES PRIOR TO10 ASSESSORS MAP 119 PARCEL 80 EXCAVATION,AND SHALL PROTECT'UTILITIES WITHIN THE WORK AREA DURING CONSTRUCTION. 13 ELEVATION DEPTH FROM SOIL SOIL SOIL COLOR SOIL OTHER 8) THE EXISTING SEWAGE DISPOSAL SYSTEM(INCLUDING CESSPOOLS)SHALL BE PUMPED,FILLED WITH SAND, SURFACE HORIZON TEXTURE (MUNSELL) MOTTLING AND ABANDONED;OR SHALL BE RE;MOVED WITH SURROUNDING CONTAMINATED SOILS AND BACKFILLED LAND COURT PLAN 5725-43 WITH CLEAN COARSE SAND. 52.1-50.9 0"-14" A LOAMY SAND 10 YR 3/3 9) ALL SYSTEM COMPONENTS SHALL BE MARKED WITH MAGNETIC MARKING TAPE OR A COMPARABLE MEANS IN ORDER TO LOCATE THEM ONCE BURIED. • 50.9-48.1 14%48" B LOAMY SAND. 10 YR 616 IF APPL(CABLE: DATUM: 10) FILL MATERIAL FOR SYSTEMS CONSTRUCTED IN FILL SHALL BE CLEAN GRANULAR SAND,FREE OF ORGANIC FINE TO MEDIUM 48.1-42.1 48%120" C 10 YR 516 LOOSE50/a GRAVEL MATTER AND OTHER DELETERIOUS MATERIALS.THE SAND SHALL BE GRADED SUCH THAT NOT MORE THAN ELEVATIONS SHOWN HEREON ARE SAND , . 45%OF THE SAMPLE,BY WEIGHT,SHALL BE RETAINED ON THE#4 SIEVE.THE FILL SHALL NOT CONTAIN ANY BASED ON AN ASSUMED DATUM MATERIAL LARGER THAN 2 INCHES.THE MATERIAL THAT PASSES THE#4 SIEVE SHALL MEET THE DEEP OBSERVATION HOLE 4 EL. 52.21 FOLLOWING GRADATION REQUIREMENTS: SOIL OLOR DEPTH FROM SOIL SOIL C SOIL SIEVE PERCENT ELEVATION OTHER LEGEND SURFACE HORIZON TEXTURE (MUNSELL) MOTTLING SOIL REMOVAL NOTE. .. SIZE PASSING #4 100% 52.2-51.2 0"-12" A LOAMY SAND 10 YR 3/3 REMOVE TOPSOIL AND UNSUITABLE MATERIAL WITHIN 6 #50 io%-I00% OF LEACHING CHAMBERS DOWN TO"C!'HORIZON #100 00/4-20% 51.2-48.9 17-40" B LOAMY SAND IOYR6/6 (BELOW EL.=48.31- SEE DOH#1&DOH A2 AND BELOW #200 O%±U m BOUND FINE TO MEDIUM EL. 48.8*- SEE DOH#3&DOH#4)AND REPLACE WITH 1w DRAIN MANHOLE 48.9-42.2 40%120" C 10 YR 5/6 LOOSE,5%GRAVEL SAND FILL IN ACCORDANCE WITH NOTE 1110. SAND NOTE: o go CATCH BASIN NOTE: ALL WATER FIXTURES TO BE WATER TESTED BY THE INFORMATION HEREON HAS BEEN PREPARED ACCORDING TO CONTRACTOR TO VERIFY ALL SEWER EXIT LOCATIONS PRIOR THE REQUIREMENTS OF TITLE 5 OF THE STATE ENVIRONMENTAL TO INSTALLATION OF ANY SYSTEM COMPONENTS. TREE CODE FOR SUBSURFACE DISPOSAL OF SANITARY SEWAGE AND LOCAL BOARD OF HEALTH REGULATIONS. GROUND WATER NOTE: ® FLAGPOLE ASSESSORS MAP 119 O THIS PARCEL IS IN A ZONE 11 GROUNDWATER PROTECTED > PARCEL 70 pq GAS METER z AREA INSPECTION NOTE L I ALEX&KA THR YN RODOLAKIS am] ELECTRIC METER SEAL THE STATE ENVIRONMENTAL CODE,TITLE 5,REQUIRES ESTIMATED SEASONAL HIGH GROUNDWATER-46';t INSPECTIONS)OF THE SEWAGE DISPOSAL SYSTEM (BASED ON GROUNDWATER CONTOUR MAPS) BY THE DESIGN ENGINEER. LOT 102 TELEPHONE BOX OF 111,254±S.F. INSTALLATION CONTRACTOR MUST NOTIFY THE DESIGN (2.55±AC.) o Jo ENGINEER PRIOR TO THE START OF INSTALLATION FOR -w- WATER LINE S DISCUSSION ON REQUIRED INSPECTIONS. -4 \N ONE (I)- 85'L x 8'W x 2'D LEACHING CHAMBER CONSTRUCT BY N vo • PLACING NINE 8'-6* x 4'-10" x 2'-0" LEACHING CHAMBER UNITS G- GAS LINE AS SHOWN WITH f-30 STONE ON ENDS AND 1'-7" STONE ON UTILITY POLE TAR0 SIDES. USE 500 GALLON LEACH CHAMBER UNITS AS MANUFACTURED BY SHOREY PRECAST OR EQUAL). GUY WIRE 51.2 LIGHTPOST 51.3 CONC.PATIO POOL AREA BRICK WALL MAILBOX LLI (Typ) X52 k 11 ---50--- CONTOUR > -X f2.3 ,53 X52.8 0 X 50.8 SPOT GRADE GARAGEJ i� PROPOSED S OVERDIG(SEE SOIL P.B. EL=53.3-t 4� SHEDAPOOL PLANT BED w.. .... REMOVAL NOTE) EQUP. 54. m w -2,,R BfZICK 2-3" 2' eCMvROCWCONC � i, �:6' 38 CO '?, OO 0 81 WALL 50 PATIO d&NTAINAJ! 139.86, z L 0 0 BRICK WALK -jL P.S. I(Typ') L EXISTING 0 w SEPTIC TANK TO w ID n. 85! BE REMOVED IX541 J P.B. 2 STORY EL co WOOD FptAME 53.9 x w DWELLING T.O.F. EDGE OF PftoPoS5D to EL > PAID P-o- 0 CLEARING TORESHOLD X53.2 i =56-0- E- - x 53r 0 0 10, 851 X&W X 2'D LEACHING CHAMBER H-10 "m) z J": MIN Co PROPOSED GAIt DETAIL OF LEACHING CHAMBER 44' 251 0 METER LOCATIO EDGE OF I CL X52.4 LAWN(TYR)l -2 0 PROPOSED 2000 GAL NO SCALE 1 0 I SEPTIC TANK(H-I 0) r7i APPROX.LOC,LEACH ROCK RET.WALL�� 0 X53.3 CO W PER TOWN OF BARNSTABL 53.3 F- AS-BUILT CARD) STEPS X522 PROPOSED H-20 z ► LAWN AREA O D-BOX(DS-9) 0 • CRUSHED 0 62 TOP OF FOUNDATION PROPOSED SHEL RAISE COVERS TO WITHIN 6" MINIMUM IYBOX INSIDE RAISE COVER TO WITHIN RAISE COVERS TO WITHIN 6"OF -41 X52.4 0 �It //1 EL.=54.9t(PROPOSED) B&L X FW X ZD I \ STONE DRIVE 0 OF FINISH GRADE DIMENSIONS MIT 6"OF FINISH GRADE FINISH GRADE(6 COVERS) LEACHING CHAMBER H-10 0 MIN SUMP 6" DB-9(H-20) 0 w FINISH GRADE=53.7* FINISH GRADE=53A FINISH GRADE=52.7:t FINISH GRADE EL.=521:t TO 52.it f :t A - :M ` ` �. W " j F- 9" 4 0 PVC MIN. 'M M o INSPECTION PORT 52 • NEW PIPE EXIT 3'MAX. Lu LIJ F- • • TDROP LU • MIN. 2"LAYER OF 1/8"TO RESERVE 0 Lu 9-(MIN.) 1/2"STONE DOW3, 0 0- Co WITHIN 3"OF GRADE 3'(MAX.) 0 UTILITY EASEMENT LANDSCAPE ul LIQUID LE ISLAND ASSESSORS MAP 119 3/4"TO 1-1/2"DOUBLE LANDSCAPE SCALE 51-\-- PARCEL 81 j, \ AS NOTED 0) OPOSED5' WASHED STONE ion DROP:2"MIN. PIPE OR FLOW PR ISLAND 3"MAX. SEE TABLE D`B LEVELER INVERT 13! OVERDIG(SEE SOIL 1z �334 96' DRAWING FILE I SEAPUITINC. f t - 2'-0"EFFECTIVE DEPTH .'t6 \f - 1��3 REMOVAL NOTE) C19350.dwg • 4'-1"LIQUID DEPTH ALL DATE HEDGE 4"DIA SCH 40 PVC PIPE 2000 GALLON(H-10) ALL OR AS REQUIRED BY SEPTIC TANK W/ L=79.41, 14 SE 1 '--1 12-05-19 MASS PLUMBING CODE SANITARY TEES GAS BAFFLE USE 46.80 1 ..,�7-629.74� DRAWN BY (TYP-) TUF-TITF OR COMPACTED BASE CONDITIONS SHOWN HEREON ARE JE -51- DAV LOCATED AS THEY EXISTED ON THE APPROVED W1 6"LAYER OF COBBLESTONE CHECKED BY WIBERM THE MINIMUM SLOPE EQUIVALENT CRUSHEDSTONE 4�-10" V-7- DEPTH TO ESTIMATED GROUND AS OF 11-22-2019. APRON • FOR 4"DIA SCH 40 PVC EDGE OF PAVEMENT Co C61 PIPE IS I/8"PER FT END VIEW HIGH GROUNDWATER 37'+ ROAD 11 8, 11-11 - ALLEY DATE-�-Deu--. /a, ICE V C14 COMPACTED BASE WITH 6" 0) - LAYER OF CRUSHED STONE ESTIMATED HIGH BENCHMARK-TOP OF CONCRETE BOUND 38.2'1 47.4-1 (LONGEST RUN) - GROUNDWATER EL.=10.0:t EL.=52.58(ASSUMED DATUM) 8 P.L.S. Q99R;�� I OUTLET TEE DEPTH 0 101t LIQUID DEPTH BELOW LIQUID LEVEL LINE(S)EXITING D-BOX MUST REMAIN LWE 0 (10-MIN.) - LEVEL FOR 2'-0"BEFORE PITCHING 8 McE E CA 4 FT 14 INCHES DOWN TO LEACHING FACILITY NO- 33602 PLAN 5 FT 19 INCHES 6 FT 24 INCHES 0-'Sss�o R- 90 No 1 30 15 0 30 7 FT 29 INCHES SCHEMATIC FLOW PROFILE SUR%\JS cn w OF SHEETS o ALL INSTALLATIONS MUST CONFORM TO THE MINIMUM REQUIREMENTS OF TITLE 5 !p cyp PROJECT NO. U. 1 inch 30 ft. 0 C19350.00