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HomeMy WebLinkAbout0019 ICE VALLEY ROAD - Health 19-Ice Val ,eyiRoad' Osterville A= 119 058 ,y h til d 'dF kM f, h n I TOWN OF BARNSTABLE Q LOCATION.,q l C e. V A k l e„-�R0I. SEWAGE # VILLAGE b 27111 lc. ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO., SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �cw .�� � � C't� (size) 60 �x I a NO:OF BEDROOMS BUILDER OR OWNER :DAv is G�eC ace PERMTTDATE: 3 OMPLIANCE DATE: Separatibn 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) Feei Edge of Wetland and Leaching Facility(If any wetlands exist ;within 300 feet of leaching facility) Feet Ftirttished by -,w S,w , C�stn ec s '4V I��oAO M�;h 1 A. e l L19 0,; i e`r 4" %a TOWN OF BARNSTABLE G LOCATION '� Q, F SEWAGE# `JILLAGE ASSESSOR'S MAP&PARCEL //9 INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY �W LEACHING FACILITY: (type) 10W -T-)i9Q U,fs (size) (o l NO.OF BEDROOMS S OWNER . PERMIT DATE: OMPLIANCE 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 Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY SPeu'rian /-1 3 3 O y j r p .r No. THE COMMONWEALTH OF MASSACHUSETTS FEE F 7 BOARD OF HEALTH r acoQieS . y APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair Upgrade ( ) Abandon ( ) - ❑Complete System []Individual Components me pr�c\ -Xce GyClf-4 Roil Ntj, �6 _V oo 1' 1QNo�y f� D �fl MGO \� l I �"� ucaliun p� F�Vx `V19� �S \V�,`ia/'1� oa655 `��bJ Map/Parcel# Address of# T lephone# LC I slallcr's Namc Cjesi ncr's Name �g Lam. 3`� Qa V P�J d, ..�� k�(\&A da3�y Address 1 S ��® Address Telephone# J✓ Telephone# Type of Building: S 6t"1 1 Ov �n4 Lot Size 'ri l04 Sq.feet Dwelling—No.of Bedrooms S Garbage Grinder ( ) Other—Type of Building No.of persons Showers Other fixtures Design Flow(min re uired) 550 gpd Calculated design flow gpd Design flow provided gpd Plan: Date A 1 Number of s eets 1 Revision Date Title S \ \ k- 1e � /� \0 t N Description of Soil(s) v`�► Soil Evaluator Form No.gk Name of Soil Evaluator &-INM Date of 1Evaluation DESCRIPTION OF REPAI OR AL ERATIONS pv M i ���� e> ,Ai �1"_� + re I5 C r- c o' o � ` X 'Ae rest c.A s The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 aZfuer agrees not place th sy tem in operation until a Certificate of Compliance has been issued by the Boar. 'tq OFM Signed Date s ft M72 FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 i t Ilk �^ No. THE COMMONWEALTH OFMASSACHUSETTS '-_ FEE �� BOARDO1�',' REALTH aC�Q`e5 .- Fj`�.� 7 �s of leCv1�`2 ' APPj ICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit"to Construct ( ')-Repair (X) Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components i 4 A� C@ Vcitk,0-4 9,80�A 7o Location Owner's Name z' hkCA \1A LEA G y. Q.p:4�o X ICX93 Ostew�U AA LASS < Map/Parcel#- Address of# T lephone# c. L G'iC�,c,�l C0�1�I�ill�, Ec ^ I staller's Name , t�esi ner's Name' c.�, d. 3c+ 9©gn v ou) (J J� ICin�s1�o )m C) "G . Address ,� \ Address " Telephone:# - Telephone# + - Type of Building: Slift• e �trv11��fluJe t1�(14 Lot Size, ���6, �04 6 Sq.feet i Dwelling--No.of Bedrooms, -< / Garbage Grinder ( ) i Other=Ty'pe.,of Building No . .,persons Showers ( ), Cafeteria ( ) Other fixtures # r, - f Design Flow(min. required SSO gpd Calcula ed'design flow gpd Design flow provided Epb gpd 's Plan: Date \ `� Number of s e ts> Revision Date .Ti tle t Q Ocn ©� j Description of Soil(s) z Soil Evaluator Form No.Qa T Name of Soil Evaluator L't Date of,Elvaluation \� 3 W.. e DESCRIPTION OFREPAI- S'ORAL. ERATIONS PvMU �i�k e><�SA1Y1 t1� + rE i5(e W �. �e .. - Ste o a s �►' - r " The undersigned agrees'to install the"above described Individual Sewage Disposal System in accordance with the provisions of i .•TITLE 5 and further agrees not to place the sy tem in operation until a Certificate of Compliance has been issued by the:Bcard of _ 1 Signed /• Date t`tN"(Its g RfCHA D I�tspeetions � ��,�, ,GRADY •Nm 38072 M �? FORM 1 - APPLICATION FOR-DSCP DIP APPROVED FORM 5/96a ~ a No. ^�` THE COMMONWEALTH OF MASSACHUSETTS FEE 66) t r BOARD OF: HEALTH . CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) r'1 ❑Complete System The undersign hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded(�;Abandoned( ) ;b 4z1/C Sfi6X 11A ljrx, o s -1 1 has been installed in accordance with the provisions of 310 C,MR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated $"" A''pproved Design Flow (gpd) Installer 1 llll e (, Designer: Inspector l/� .lfi//I D(.•I 11 PDate The issuance of this certificate shall not be construed as a,guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 ti i No.�� i-���� THE COMMONWEALTH OF MASSACHUSETTS FEE /�n �N BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) Repair ( ) Upgrade (><) Abandon ( ) an individual sewage ` disposal system at �1A►-4- 110-ple,4 as described j in the application for Disposal System Construction Permit No. �'' 7�� dated �2��� " Provided: Construction shall be completed within three years of the date of this permit.All local cQnditions Must beQmet. Date 3/� Board of Health �� FORM 2 DSCP DEP APPROVED FORM 5/96 � I FORM 1255 (REV 5/96) H&W HOBBSB WARREN rM PUBLISHERS- BOSTON i Y ROAD ICE VAI-UE L=132. > > 3 � L 11 61 .91 r54 O cc, e„ Co I'+ O' Cn U1 -p (A 52.91 EX DWEI-LING Z ' un N PROPOSED o �� 3.5'x12.04' C° WINDOW WELL LF MBLU 119-058 19 ICE VALLEY ROAD OSTERWLLE, MA N -P. SEPTIC FROM ASBUILT ON FILE AT THE TOWN 226 91° HEALTH DEPARTMENT BUILDER TO CONFIRM CER TIFIED PL 0 T PLAN KELTY RESIDENCE I CERTIFY THAT THE IMPROVEMENTS SHOWN of >>r 19 ICE VALLEY ROAD MEET THE SETBACK REQUIREMENTS OF �P�t� Assgo OSTERVILLE, MA �� do DATE: DEC. 15, 2015 DRAWN: RBS OF THE TOWN OF BARNSTABLE. Roes �, JOB #: Sls2 o SYKES SCALE: 1"=60' DWG. CPP No. 35418 EASTBOUND �O�� LAND SURVEYING, INC. ST - `.�'€`. P.O. BOX 442 ROBE SYKES, P.LS. DATE AL FORESTDALE, MA 02644 508-477-4511 ^J ii TOWN OF BARNSTABLE LOCATION k g 1 C C V A k 1 c,'R0I. SEWAGE # (?Q VILLAGE 0 s e1 �:.. �C. ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.25 . a C c- l o li e e- - H 1 SEPTIC TANK CAPACITY 0 G I, LEACHING FACILITY: (type) �cw ►>� .-r^.� (�'�� (size) 60 X 1Q NO.OF BEDROOMS BUILDER OR OWNER :DA V L o G�-e C 6,y PERMITDATE: 3 - Q-Si Q 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 Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Cis 1h�wco Mkt ST, 181 k I01� �z`t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 19 ICE VALLEY RD Property Address JITAO NIU Owner Owner's Name information is required for OSTERVILLE MA 4/14/14 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your DOUGLAS A BROWN 7,20 cursor-do not use the return Name of Inspector key. D.A. BROWN INC ' Company Name t P.O. BOX 145 Company Address ; CENTERVILLE MA 02632 City/Town State Zip Code 508420-4534 S14297 Telephone Number License Number i B. Certification I certify that I.have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes = ❑ Conditionally Passes' ❑.-Fails ❑ Needs Further Evaluation by the Local Approving Authority x Y; 4/14/14 , Ins ctor's Si ature Date w " The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or Y has a design flow of 10,000 gpd-or greater, the inspector and the system owner shall submit the report to the appropria$e regional office of the DEP. The original should be sent to tfie system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspec#ion does:not:address how the system will perform in the.future under the same or different condrtioos,of-use. t5ins 31t 3 Title 5 Official Inspection F S b urfaoe Sewage Disposal System•Page 1 of 17 .F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4 M , 19 ICE VALLEY RD Property Address JITAO NIU Owner Owner's Name information is required for OSTERVILLE. MA- • . 4/14/14 ` every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary' Check A,B,C,D or E/always complete,all of Section D A) System Passes: ® 1 have not found aniinformation 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 ONLY RECORDS AVAILABLE AND AS-BUILT SHOW THE SYSTEM BEFORE THE HOUSE, WAS RENOVATED AND OR ADDED ONTO THERE FOR THE LATEST AS-BUILT AT THE BOARD OF HEALTH WAS NOT ACURATE. WE WERE ABLE TO LOCATE THE SEPTIC TANK OPENED IT AND VIEWED THE DISTRIBUTION BOX BY CAMERA. B) System Conditionally Passes: ' ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,,upon completion of the replacement or repair,as approved by the Board of Health, will pass.. , Check the box for"yes", "no"or"not determined"(Y,'N, ND)for the following statements:If"not determined," please explain.The septic,tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the' Board of Health. *A metal septic tank will pass inspection if it is structurally sound;not'leaking and if a Certificate of, ' Compliance indicating that the tank is less than 20 years old is available. z El Y 0 N E] ND (Explain below): L. t5ins•3113 v Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 + ' Commonwealth of Massachusetts . .. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 ICE VALLEY RD - 'A • ' _ • - Property Address - JITAO NIU Owner Owner's Name information is required for OSTERVILLE '� MA 4/14/14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.); ❑ Observation of sewage backup or breakout 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 (Explairi 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 0 ND (Explain below): ❑ obstruction is removed; • ❑,Y- `❑ N ❑ ND(Explain below): ` C) Further Evaluation is Required by the Board.of Health-.- El 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.. fi 1. System will pass unless Board of Health determines in accordance with 310 CMR" ' 1.5.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ' Cesspool or privy is within 50 feet of a surface water- ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 , ` Commonwealth of Massachusetts " Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments:` y M , 1910E VALLEY RD :{ Property Address JITAO NIU Owner Owner's Name information is OSTERVILLE MA 4/14/14.' required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS-is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has aseptic 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.; A ❑ 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. ' 3. Other: - D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for III inspections: Yes -No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters.' " due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded ❑ ® or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available.volume is less than Y2 day flow fi t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17; Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form Not for Voluntary Assessments , M 19 ICE VALLEY RD Property Address JITAO NIU Owner Owner's Name information is required for OSTERVILLE MA 4/14/14 every page. City/Town State' Zip Code Date-of Inspection B. Certification (cont) Yes No ❑ ® Required pumping more than 4 times°in the last year NOT due to clogged or obstructed pipe(s). Numberof.times pumped: ❑ ® -Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ®, Any'portion,of a cesspool or privy is within 50 feet of a private water supply well.,. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,. provided that no other failure criteria are triggered. A copy of the analysis, and chain of custody must be attached to this form.] El : ® The system is a cesspool serving a facility with a design flow of 2000gpd-, 10,000gpd. The system fails. I have determined that one or more of the above failure E] ® criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 101000 gpd to 15,000 gpd. For large systems, you.must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply L El system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well U If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 ICE VALLEY RD Property Address JITAO NIU - Owner Owner's Name information is OSTERVILLE MA 4/14/14 required for ' every page. CitylTown State Zip Code - Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to-each of the following: Yes No ❑ ® Pumping information was provided by the owner;occupant, or Board of Health El ® Were anyof the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system'obtained and examined?(If they were not available note as N/A) ® ❑ • Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ' ® ❑ Were all system components, excluding the SAS, located on site? . ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,-depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? . The size and location of the Soil Absorption System(SAS)on the site has . ` been determined based on: ® ❑ Existing.information: For example, a plan at the Board of Health. El Determined iri the field (if any of the failure criteria related to Part C is at issue ® approximation of distance is unacceptable)'[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: ` Number of bedrooms(design): 5 5 _ . Number of bedrooms.(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms' 550 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 19 ICE VALLEY RD Property Address { JITAO NIU Owner Owner's Name information is required for OSTERVILLE MA, 4/14/14 every page. Citylrown State" Zip Code Date of Inspection D. System Information Description: ACCORDING TO THE DESIGN PLAN THE SYSTEM'CONSISTS OF A 1500 GALLON TANK= DISTRIBUTION BOX AND 7 LEACH CHAMBERS SURROUNDED WITH STONE Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection 0 Yes ❑' No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No ' t Water meter readings, if available(last 2 years usage(gpd)): Detail: 2012----=-----389GPD 2013-------303 GPD DID NOT ENTER HOUSE SO I CAN NOT VERIFY IT, HAS NO DISPOSAL BUT SYSTEM WAS NOT DESIGNED FOR DISPOSAL" i Sump pump? , , ❑ Yes- ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: x Type of Establishment: Design flow(based on 310 CMR 15.203): Gauons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes ❑ No Industrial waste holding tank,present? ; ,, ❑ Yes,❑ No' Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No f Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 19 ICE VALLEY RD' ' Property Address + JITAO NIU Owner Owner's Name information is required for OSTERVILLE MA 4/14/14 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: a. Date ; Other(describe below): r' General Information Pumping Records: - Source of information: i Was system pumped as part of the inspection? ❑ Yes ® -No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ; ® Septic tank, distribution box, soil,absorption system ❑ Single cesspool., ❑ . • 8 ' v ' •• Overflow cesspool , ❑ Privy ❑ Shared.system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator,under contract ❑ Tight tank. Attach a copy•of the DEP approval. ❑ Other(describe):' ' t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17, a - e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 19 ICE VALLEY RD Property Address JITAO NIU Owner Owner's Name information is required for OSTERVILLE MA 4/14/14 ' every page. City/Town State, Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of~information:' 1999 ACCORDING TO PERMIT Were sewage odors detected when arriving'at the site?' ❑ Yes ® No Building Sewer(locate on site plan): , Depth below grade: I feet r Material of construction: ❑ cast iron : ❑40 PVC ❑'other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 2.5 Depth below grade: feet Material of construction: - ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal;list age: years w ;. is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes'❑ No . , Dimensions: 1500 PER PLAN Sludge depth: MODERATE • _ . . t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 19 ICE VALLEY RD Property Address JITAO NIU Owner Owner's Name information is required for OSTERVILLE MA 4/14/14 every page. Cityfrown State 'Zip Code.. Date of Inspection D. System Information (cone.): Septic Tank(cont.) Distance from top of sludge to'bottom of outlet tee or baffle Scum thickness MODERATE Distance from top of scum to top of outlet tee or baffle` Distance from bottom of scum,to'bottom of outlet tee or baffle- How were dimensions determined? Co{nments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, {p id levels as related to outlet invert, evidence of leakage, etc.): ;RECOMMEND PUMPING IN THE NEAR FUTURE AND EVERY 2-3 YRS THERE AFTER Grease Trap(locate on site plan): Depth below grade: feet f' ' Material of construction: = ❑ concrete ❑,rrietal ❑ fiberglass ❑ polyethylene ❑ other(explain):, Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle ' Date of-last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 ICE VALLEY RD Property Address - JITAO NIU Owner Owner's Name information is required for OSTERVILLE MA , 4/14/14 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) . Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding,Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: - Yt" • Material of construction: , ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions:, Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No , Alarm level: ,Alarm in workirig order:. ❑ -Yes ❑ No Date of last pumping; u Date Comments(condition of alarm and float switches, etc.): Attach_copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No ., t5ins•3/13 f Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 19 ICE VALLEY RD Property Address - JITAO NIU Owner - Owners Name information is required for OSTERVILLE MA 4/14/14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): ' Depth of liquid level above outlet invert 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.): DO TO THE UN ACURATE AS-BUILT CARD THE D-BOX WAS VIEWED BY CAMERA AND DID NOT SHOW SIGNS OF FAILURE AT,TIME OF INSPECTION 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.): • t *If pumps or alarms are not in working order,system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): . If SAS not located, explain why: , ' S.A.S WAS NOT OPENED/ LOCATED DUE TO THE AS-BUILT CARD NOT BEING UPDATED' WHEN THE PROPERTY WAS ADDED TO OR RENOVATED THERE WERE NO MEASUREMENTS THAT WORKED AT ALL MAKING IT IMPOSSIBLE TO LOCATE THE S.A.S:IN A REASONABLE MANNER t5ins•3/13 fi Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments, s 19 ICE VALLEY RD Property Address JITAO NIU Owner Owner's Name r` information is required for OSTERVILLE MA 4/14/14 every page. Cityrr'own State Zip Code Date of Inspection. D. System Information (cost.) ' Type ❑ leaching pits number: ,» . -7 b ® leaching chambers . ' number: ❑ leaching galleries -'y F number: - ❑ leaching trenches number, length:. F ❑ leaching fields ; - number, dimensions: ' ❑ overflow cesspool ,.`number El innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure,,level of ponding, damp soil, condition of vegetation, etc.): 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 c `Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑. Yes ❑ No', , t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments »M �< 19 ICE VALLEY RD w Property Address JITAO NIU Owner Owner's Name information is required for OSTERVILLE MA 4/14/14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) - Comments(note condition of soil;-signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on'site plan): Materials of construction: Dimensions ' Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding; condition of vegetation, etc.): t5ins•3/13 r•1• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts ` - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 19 ICE VALLEY RD Property Address JITAO NIU Owner Owner's Name information is MA t , 4/14/14 required for OSTERVILLE , every page. Cityrrown State Zip Code "Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below:. ❑ hand-sketch in the area below ® drawing attached separately A - A t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 19 ICE VALLEY RD Property Address JITAO NIU r Owner Owners Name information is required for OSTERVILLE MA ` 4/14/14 - every page. Citylrown State Zip Code Date of Inspection D. System Information (cost.) Site Exam: ® Check Slope ® Surface water .® Check cellar ' ® Shallow wells GREATER THAN 5. Estimated depth to high ground water:._ feet Please indicate all methods used to determine.1the high ground water`elevation: - t • ® Obtained from system design plans on record If checked, date of design plan reviewed: APRIL 14TH 2O14 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Boar6of Health-explain' ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain:. You must describe how you established the high ground water elevation: DESIGN PLAN BY GRADY CONSULTING LLC Before filing this Inspection Report, please see Report Completeness Checklist on next page. - t5ins•3/13 Title 5'Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 19 ICE VALLEY RD z Property Address JITAO NIU k _ Owner Owner's Name information is required for OSTERVILLE MR, 4/14/14 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked Z .Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater Z.Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file V t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE. G LOCATION 1A164 - R� SEWAGE#_3 p S VII LAGS_ O rvyILt ASSESSOR'S MAP:&PARCEL 119 CZS� INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type)' FI ob+ 11��,TTU ibis '(size) (o OX NO.OF BEDROOMS S •, OWNERory PERMIT DATE: OMPLIANCE DATE: Separation Distance Between the:, h Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist , on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist ' within 300 feet of leaching facility) Feet FURNISHED BY_�/l SOCtlEinn -:S i { "3AJc 14W 51,N a 1 73 Appro, T R ; 3 13 http://www.townofbamstdble.us/Assessing/HMdisplay.asp?mappar=11905 8&seq=1 4/14/2014 i � is t _ "', TOWN OF BARNSTABLE BOARD OF HEALTH 2 ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date J Time: In Out Owner f - U ►" V Tenant Address a �'^"" Address 19C�-- Compliance Remarks or Regulation# Yes O Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply —•3p - 1�-- 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal i 16. Sewage Disposal O 17. Temporary Housing 15f y� 3 9U E 18. Driveway Width a 'U �I ' 3 0 6 Z 9-d 19. Number of Tenants Observed 14 �"� PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) c Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here s COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF.ENVIRONMENTAL PROTECTION a CD r� co, - Co 1 w TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSF SSMIRNTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM- PART A CERTIFICATION Property Address: 191ce Valley Road Osterville. MA 02655 Owner's Name: David Gregory Owner's.Address: `J 9 97 Date of Inspection: October 13, 2006 Name of Inspector: (Please Print) James Al. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Ostervllle,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected'the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Nee Further Evaluation by the Local Approving Authority 4Fai Inspector's Signature: Date: October 17. 2006 The system inspector shall sub a copy opection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I r Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 ke Valley Road Osterville. MA Owner: David Grezry Date of Inspection: October 13, 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: • 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 ke Valley Road Osterville. MA Owner: David Grezory Date of Inspection: October 13 2006 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CM 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _. Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has aseptic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS;is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 191ce Valley Road Osterville, MA Owner: David Gregory Date of Inspection: October 13, 2006 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6 below invert or available volume is less than %day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located,in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 f Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 191ce Valley Road Osterville MA Owner: David GreQory Date of Inspection: October 13 2006 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ ✓ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS, located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. . _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 19.Ice Valley Road: y Osterville MA Owner: David Gregory Date of Inspection: October 13 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): N/aJ DESIGN flow based on 310 CMR 15.203 (for example: 110`gpd x#of bedrooms) 550 Number of current residents: n/a _ Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No _ Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): and Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no)': g Water meter readings,if available: Last date of occupancy/use: OTHER(describe): w GENERAL INFORMATION - Pumping Records Source of information: Tank was pumped after inspection for maintenance Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--.How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system w Single cesspool Overflow cesspool Privy , Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology..Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: _Installed in 1998-per as built card Were.sewage odors detected when arriving at the site(yes'or no): No 6 v , f Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 191ce Valley Road Osterville, MA Owner: David Grezory Date of Inspection: October 13. 2006 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,-evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 42" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 izaL Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.). Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage The inlet cover was 13"below grade. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): ^ 7 b Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: 19 Ice Valley Road Osterville, MA Owner: David Gregory Date of Inspection: October 13,2006 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): - Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,'ete): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) " Pumps in working order(yes or no): Alanns in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 Ice Valley Road Osterville, MA Owner: David Gregory Date of Inspection: October 13, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: ✓ leaching galleries,number: Flow diffusors-(60 x 12)-per as built card leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The Flow diffusors were dry and clean. No sign of failure A video camera was used for the inspection CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None(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.): 9 f, r Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 191ce Valley Road Osterville MA Owner: _David Gregory Date of Inspection: October 13 2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 3AJr, B � 3 i 3 O y 10 i ?' Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19Ice Valley Road Osterville, MA Owner: David Gregory Date of Inspection: October 13. 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Esti hated depth to ground water 30+/- feet Nease indicate(check)all methods used to determine the high groundwater elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ` Checked with local Board of Health-explain: topographic and water contours maw_ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: _Using Barnstable topographic and water contours traps the maps were showing approximately 30'+/ to groundwater at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 —_ I P Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept.of Environmental Protection k1F One winter Street,Boston,Ma. 02108 isle Septic, D.E.P. Title V Septic,Inspector P.O. Box 2119 TeaticketyMA 02r536^•�_ WILLIAM F.WELD (508 15,�6�4,68'1 '-- 1 Governor ,�Y A ARGEO PAUL CELLUCCI 'per '/�C�'� � Lt.Governor �� SUBSURFACE SEWAGE DISPPAORTLASYSTEM INSPECTION FORM �F� i CERTIFICATION y�'oc� tS lq�r Property Address: 191ce Valley Rd.Osterville Address of Owner: Date of Inspection: V22198 (If different) 0 Vi Name of Inspector: John Graci Richard Giberti:PO Box 557 Osterville 02655 1 I am a DEP approved system inspector pursuant to Section 15.340 of Title,%(310 CMR 15.000) \6 Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes This Inspection Is based on criteria dented In TO V _ Conditiona [)yases code 310CMR16.303.My findings are of how the system Is performing at the time of the inspection.My Inspection does _ Needs Furt r aluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the , Falls septic system and any of Its components useful Itre. Inspector's Signature: Date: 4127198 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(3b)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C,or D:' A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: 8] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Corripliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection-,or the septic tank,whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised oCIA17) One Winter Street • Boston,Massachusetts 02108. • FAX(617)556-1049 is Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 ice Valley Rd Osterville Owner: Richard Gibertl:PO Box 557 Osterviile 02055 Date of Inspection:412219B _ Sew.ane backup or.breakout or hiah.static water level observed.in.the distribution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced - obstruction is removed distribution box is leveled or replaced _The system required pumping more than four 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 obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT'THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. . f The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other e D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in ' 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _ — Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. i _ Discharge or ponding of effluent to the surface of the ground or surface wales due,lo en overloaded ul clugyed cesspool. _ SAS is in hydraulic failure. (revleed 04127l87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 ice Valley Rd,Osterville Owner: Richard Giberti:PO Box 557 Osterville 02055 Date of Inspection:4122199 D]SYSTEM FAILS(continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. — Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 ll of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (ravlsad 0412797) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 19 ice Valley Rd.Osterville Owner: Richard Gibertl:PO Box 557 Osterville 02855 Date of Inspectlon:4122M$ Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following: _x_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not.been Introduced Into the system recently or as part of this inspection. x As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _y_ — The site was inspected for signs of breakout. x All system components,excluding the Soil Absorption System, have been located on the site. x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. x The size and location of the Soil Absorption System on the site has been determined based on — — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is — — unacceptable)(15.302(3)(b)] (revleed 04127)971 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 19 ice Valley Rd.Osterville Owner: Richard Giberd:PO Box 557 Osterville 02655 Date of Inspection:4122195 FLOW CONDITIONS RESIDENTIAL: d/bedroom for S.A.S. Design flow: g p Number of bedrooms: a Number of current residents: 2 Garbage grinder(yes or no): Yee Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): nra Sump Pump(yes or no): No Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: n1a Last date of occupancy: n1a OTHER:(Describe) rya Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has been pumped ons time. System pumped as part of inspection: (yes or no)Yes If yes,volume pumped:2500 gallons Reason for pumping: Maintenance TYPE OF SYSTEM Septic tank/distribution box/soil absorptions system x Single cesspool .Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records, if any) I/A Technology etc.Copy of up to date contract? 4 Other: APPROXIMATE AGE of all components, date Installed(If known)and source information: 20•yens old. Sewage odors detected when arriving at the site:(yes or no) No (revised 04127)971 T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 ice Valley Rd.Osterville Owner: Richard Giberth PO Box 557 Osterville 02655 Date of Inspection:4122198 SEPTIC TANK: a (locate on site plan) r. Depth below grade: ria Material of construction:_concreate_metal_FRP_Polyethylene_other(explain) If tank is metal,list age Na . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: rda Sludge depth:rda Distance from top of sludge to bottom of outlet tee or baffle: rda Scum thickness:We Distance from top of scum to top of outlet tee or baffle:rda Distance form bottom of scum to bottom of outlet tee or baffle:rda How dimensions were determined: rda `• _ f , 4 y Comments. r (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Na GREASE TRAP: (locate on site plan) Depth below grade: raa Material of construction: _concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rda d Scum thickness:Wa Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee of baffle:Na Date of last pumping, Comments:. (recommendation for pumping,condition of inlet and outleftees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Ma BUILDING SEWER: , (Locate on site plan) Depth below grade: 2 Material of construction:_cast iron=40 PVC_other(explain) a Distance from'private water supply well or suction linetown Diameter: 4° rw tm' nts: (conditions of joints,venting,evidence of leakage,etc.) a (revleed 0427/9T) • is � SUBSURFACE SEWAG E DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 ice Valley Rd.osterville Owner: Richard Glberti:Po Box 557 osterville 02655 Date of Inspection:4122195 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: nia Material of construction:_concrete_metal_FRP_Polyethylene other(explain) Dimensions: nra Capacity: nra gallons Design flow: rva gallons/day Alarm level:_va Alarm in working order?_Yes 7—No- Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.)' rim a DISTRIBUTION BOX: (locate on site plan) F Depth of liquid level above outlet invert: nra Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) nla PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Ye: Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) nra (revleed 04l27187) + SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 19 ice Valley Rd.Osterville Owner: Richard Gibertl:PO Box 557 Osterv9le 02655 Date of Inspection:4122(9s SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: rya Type: leaching pits,number: Ne leaching chambers,number:rda leaching galleries,number: rda leaching trenches,number,length: rda leaching fields,number,dimensions:We overflow cesspool,number:twoceespoolovertlowsVXV Alternate system:-rda Name of Technology._rda Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) System and all componente are structurally sound and functloning properly,e2 has never had more than T of water In k.ft now has 11"ofwater In It CESSPOOLS:x (locate on site plan) Number and configuration: one Depth-top of liquid to Inlet invert:e" , Depth of solids layer: e" Depth of scum layer: Dimensions of cesspool: Materials of construction: brick Indication of groundwater: rda inflow(cesspool must be pumped as part of inspection) rda Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Cesspool and all components are structuraey sound and funcWning properly.All covers are to grade. PRIVY: (locate on site plan) Materials of construction: We Dimensions: We Depth of solids: nfa Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) rda (revlesd 0427197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 191ce Valley Rd Osterville Richard Giberd:PO Box 557 Osterville 02055 4122198 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) a � — i e (rnvludOW197) Pa9• ! of 10 SUBSURF 'a;E SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 191ce Valley Rd.Ostervllle Richard Marti:PO Box 557 Osterville 02655 4122199 Depth of groundwater .12. Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed). USGS maps and chars (rnvludOW197) page 10 of 10 1 Town of Barnstable P# Department of Health,Safety,and Environmental Services oFttHWE Public Health Division Date --3-CT� Q. 367 Main Street,Ityannis MA 02601 8A(U78TAB[$ � Date Scheduled 1 2- 3 - - lEo t,�ted" 1� Time � Do Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: t '�GN (L(� �� Ap Witnessed By: hwIIJG? . :LpCATI01 & + NIi�RA L�IFORNIATI4N �a>z�Location Address Owner's Name ���I>7 o� I0t I C_E 14AL -f- V 0 A t2 Address Assessor's Map/Parcel: /� /O s-fJ Engineer's Name P-A 1D`� t j�e,L) Le Ell, NEW CONSTRUCTION! ` REPAIR Telephone 11 Land Use IZE51 nL-nyt; Slopes(%) O± Surface Stones iJ 0 Distances from: Open Water Body �A I P It Possible Wet Area ADD_ft Drinking Water Well ��(1 Drainage Way_ R Property Line 1CJ0 R Other -TyQN) lt� (Z� R 4m + SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 7O ►C� Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: �t4o}J Weeping from Pit Face Estimated Seasonal High Groundwater l(il/\` A�ihJY1�YJ A! 'DO( , I�V �j.(Ot It kl(Coo d' 7� s.oi r. (�V b 'T1NATIC1N 'ORSEAO.rA ,> GT:'VVAT . ... . .... ; > >>:;<:»<>::; :::::::::,.:::.....:,.....:.:.......:...:.:::::::::..:.....::::..::::.. .::::.:::::.::::::.::: ::::::::..............;..:ETt:TAT3I� ::::,::::::::::: . Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment It. +-index Well N___.-._ 'Reading Date:_ Index Well level...--- Adj.factor Adj.Groundwater Level ,.>: :;::::::::>;>::::>::;:>::>::;:....PERC( LATLOIY... EST. . ........::.: :.:::::::. n�te l :.. .: Itde:. ::::::::::::: :. Observation a Hole M r Time at 9" Depth of Perc J� Time at 6" Start Pre-soak Time® orl Time(9"-V) End Pre-soak Z15 6 AL. 1►.a ej �)aJ Rate Min./Inch L Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) l� Original: Public Health Division Observation Hole Data To Be Completed on Back j 'c DE P'UBSPRA'1'TbN HpT� LOGu1e# 1 ... .::. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) A (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. f?F, o Gravel) '-A901 ioA I D `I `/E �10 C) �r/� t'l o I2-0" 68 10 DEEP QBSERVATI N kI0LE'L .G I Ode;# .... .... Depth from Soil Ilorizon I Soil Texture Soil Color I Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % DE 1� OAS R A`Y'IUN I IJk toi.G : :.<..: .I 01e# . .. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. 0 DEEP OBSERVAT1.ION HOLE LOB Ho1c# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. ° Gravel) v Flood Insurance Rate Maw Above 500 year flood boundary No_/ Yes 1/ +. Within 500 year boundary No ✓ Yes Within 100 year flood boundary No--Z/ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? �1?�42 If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,e7:Z and experience described i .310 CMR 15.017. Signature Date 4,21 6'-W- 4'-14 T S�� P411 1 •p 5'-114OP N -1c MECHANICALS I o CV i t, 0 12'-1411 Y 2 h" 4'-34" rIN 5'-4i1 _ ao _ 13'-2" N CV UNFINISHED SPACE EXISTING 3'-82" 35'-6" 40'-72" Cape CAD Design BASEMENT RENOVATION FOR: GENERAL NOTES: NDre. SCALE: DWG. NO.: I. SOME OF THE MEASUREMENTS ARE APPROXIMATE THE PLANS SHOWN ARE THE 50LE PROPERTY OF CONTRACTOR IS TO VERIFY EXISTING CONDITIONS THE DESIGNER AND CANNOT BE COPIED, 3/3 2" AND DIMENSIONS IN THE FIELD PRIOR TO START OF REPRODUCED AND/OR ALTERED,USED FOR PERMIT P.O. BOX 8 O 6 19 I C E VALLEY ROAD WORK AND/OR FILING WITHOUT THE EXPRESSWRITTEN DESIGNER, 2. All WORK SHALL CONFORM TO THE CONSENT OF THE DESIGNER,PATRICKICK RIMING70N, MASSACHUSETTS STATE BUILDING CODE(LATEST UNDER THE ARCHITECTURAL COPYRIGHT PROTECTION DATE: M A RST O N S MILLS O ST E RV I L L S, M A EDITION)AND ALL OTHER APPLICABLE CODES. ACT OF 1990. 12/19/20 f 5 3. ANY 015CREPANCIES.ERRORS AND/OR OM155IONS IN THE NOTES,SHALL BE BROUGHT TO THE ATTENTION OF THE DESIGNER PRIOR TO COMMENCEMENT OF CONSTRUCTION. PROCEEDING WITH CONSTRUCTION 7 ^/f 4 CONSTITUTES ACCEPTANCE OF THESE DOCUMENTS REV: 5 O L//'�8 O / O / 1 AND ANY DISCREPANCIES, OF AND/OR MI 0 0 /00/0 0 0 0 OMISSIONS BECOME THE RESPONSIBILITY OF THE BUILDING CONTRACTOR PLAN d ( 4'-2" 6'-01" 4" TRIM COLUMNS i r CUSTOMER SUPPLIED LIGHTING WORKOUT ROOM TILED OR ENGINEERED RUBBER/PLASTIC FLOORING THROUGHOUT 5'-114' ,WORKOUT ROOM 6' Z� SQUARES FLOORING r CUSTOM BOOK CASES ----- ---- NEW DOOR TO CLOSET ELECT CAL 'CLO UNDER STAIRS t 1 6 NEW DOOR LEGEND NEW DOOR o PROPOSED BAR WITH SINK 4' r .FULL WALL riN 3 WINDOWS 'l T ®PARTIAL WALL s EXACT SIZE T.B.D. N N NEW WINDOW WELL MECHANICALS _ CLOSE T 0 o OPEN BALUSTERS UPSTAIRS - AT rn LESS AC/HE PROPOSED DUCT 12'-14' NEW DOORS ACCESS HATCH _, >.• ' NEW VANITY Approximately: 28"x22" FLUORESCENT LIGHTS. �� ` • `•,,- EXISTING UPSTAIRS DOOR TO BASEMENT TO BE REMOVED AND ENTRY LEFT OPEN TO CONTINUING DOWN STAIRS EJECTOR PUMP t. CEDAR CLOSET Y' Walls&Ceiling ' 6" _ EXHAUST FAN FUL L SH ELF WITH Ln HANGING BAR UNDER � NEW TOILET SHELVES T.B.D. - -: T� NEW PREFABRICATED r- SHOWER _ T AC/HEAT CONDENSER UNFINISHED SPACE N M FINISH OAK TREADS NEW DOORS L OPEN BALUSTERS 82 - (35'-6" EXISTING WALL J OSEDPROP40'-72' �• GENERAL NOTES. NOTE: SCALE: DWG. NO.: /�/f�n 8 AS E M E N T RE N O V AT I O N O R 1 ' SOME,Or THE MEASUREMENTS ARE APPROXIMATE THE PLANS SHOWN ARE THE SOLE PROPERTY OF 3/3 211 - I' C Cape C AD D e s g CONTRACTOR 15 TO VER FY FIELD P NG CONDRIONS THE DESIGNER AND CANNOT D-COPIED, AND DIMENSIONS IN THE FlELD PRIOR TO START OF �D OR F UENGAWIT OHOUf THEEIXPRE55 FOR PEWITIT F WORK. CONSENT OF THE DESIGNER,PATRICK RIMINGTON, !t P.O. �Q7 {/^� 19 ICE VALLEY ROAD Z• 5ACHUKSHALL 55TATEFORM TO DINGCO DATE: BOX �/O v MASSACHU D ALL STATE BUILDING CODE fLATEST q�OPER T�990.CHITE`TURAL COPYRIGHT PROTECTION 12/19/20 15 3.Mz)15C ALL OTHER APPLICABLE CODES. 3. ANY DISCREPANCIES,ERRORS AND/OR OMISSIONS I OF THE DE51GNER PRIOR BROUGHT COMMENCEMENTNTION M AR5T0 N S M I LL5 O5T E KV I LLE 5 M A CONSTRUCTION. PROCEEDING WITH CONSTRUCTION REV: C0N5TRUTF-S ACCEPTANCE OF THESE DOCUMENT5 ANDIOR OO/OO/OOOo ' //� 7 7 4 OMIS ON5 BECOME THE RE5FO 51BIUTY OF THE 5 O8 2 6O / O • - BUILDING CONTRACTOR PLAN 4 .XI�eJ�'`' } » X• '':y .p, f' :Y'W � die e..: ' Adif{✓n.—�`+,,. yk+':-r ..� ..,�...a xi � � � i4 ;. A,S? �.w-. b.. _ .. ,.,ji..- +,. .sy a... ..z• Mom.^.~.. .,x.,-..e_+.eti :..�..� - �-,a le'::�—.. �S1w' n; -_-•._ _'�'�•. — .-.a..-.....��r...wu_..i.uk.r..�:...4`' .._ ,.:Asx� _._ ----.r--�------_ • • i E h. V - e�'r o N ilNf �r! "kA Nu G,f '�'CaN a� _ I-tcUeol_ "t-b H i i I 4 c f f 4 Z r y ale q yy "S I1 { F tl -- I t I r� r� 'N t <� F [ I. y" 1 i I �+ 77, om lZ 4 ,rz- > i .............. s — —' ,' ,D cLp• t � 5 i •N 1 f 1-24„0 MANHOLE COVER BROUGHT WITHIN 6" OF FINISH GRADE All 9 ��� t 4 •� r� k EL. 98.88 , , INSTALL ACCESS COVER WITHIN INVERT LEVELER CAPQj RF-1 & WPk 4S=. 8.2 RECOMMENDED 12 OF FINISH GRADE DISTRICT: r MIN. AREA: 43,560 SFu" 5,*{� , E � � , •t » +97.0 PVC T R MIN. FRONTAGE: 20' F �F; T ;� "` `' `� �� +89.0 Z s. +90.0 FINISH GRADE -� ao 125' i ,l f Q'i LOT WIDTH: , ' 'IIu- 30' L r` ' *� s CH 40 " 3 PEASTONE w ►--� NOTE. FRONT: (b PVC SCH 40 c� N a °r M „ • r:k , �✓r "` P EL. 94.88 » 3< sas 3t x . 1 , k � � f° °� - EL.86.48CONTRACTOR MAY SUBSTITUTE 1-62' LONG (100' ALONG ROUTE 28) � � ,' � �" t' '� ' 3 �» 5=.13 --. s€ r� ' ° EL. 91.4t . 94.60 S=.D1 0 o 0 o Cl- ll) x 11' WIDE x 2' DEEP PLASTIC INFILTRATOR 15' �Y. a$ �. - 0 0 0 0 0 o q7 ♦ CoLo SIDE: _a es` �,� •„ R GAS EL. 86.$0 " CRUSHED S10NE EL. 86.60 24' 0" 40-0" SYSTEM W\9-6.25' LONG x 3' WIDE REAR: 15' �M`y1+ d '*$ - ';'`� 'y -' � `• BAFFLE 4 35 4rT Y* °�k T�,l r \ ✓ X f,u a /`,. 41 ,5 b3 �5..6. ."d! sf., .'e^ — PLASTIC INFILTRATORS FOR THE PROPOSED , 4 Lt *• C3 . . , ,. EL 84 48 Z (COVENANTS REQUIRE 50 4 Iitsmd � , REIN. CONC. DIST. BOX �,,.,� © ao W 8 OUTLETS r ; h f •. ,� �* 10 MIN USE t-60 LONG x 12 WIDE x 2 DEEP , PRECAST CONCRETE CHAMBERS 4P s '� $ , LEACHING CHAMBER SYSTEM WITHQj ROM ALL L07 LINES tlstl ,. -.x , i a » TO BLDG CRUSHED STONE ` 24"-3 4" TO 1 1 2" L X WASHED STONE 7 PRECAST CONCRETE LEACHING CHAMBERS 0 20' MIN TO BUILDING 12' 10' MIN. �- 9 ::1 € # . . a v _; :� 1 *: ': r a W 60 O �6 �8 \ 9 9 1500 GAL. (MIN.) PRECAST CONCRETE ci > N o SEPTIC TANK W/2 PVC SCH 40 TEES Q \ / LOCATION MAP SCALE: 1 = 2083 � lo I .� u \ 'IBnd \\ NO9'5f 25'"� �e ' �' - END SUBSURFACE SEWAGE DISPOSAL SYSTEM ASSUMED w 00 \ (NOT TO SCALE) GROUNDWATER EL.= 79.48 > z T (NONE ENCOUNTERED) p op tfX157)WG 1 �-- XIS SEPTIC DESIGN �' � ��SEPTIC SYSTEM / , \ ORC (PUMP & FILL) �`� z 1 . DESIGN DAILY FLOW: 5 BR. x 110 GPD 550 GPD v TREES 2. SEPTIC TANK: 550 GPD x 2 = 1 100 GAL. USE: 1500 GAL (MIN) I LtMfT OF ! \ \ \ \ ,\ 1 14.0'f 0 �, \ �� 197,E Q 4 ` 3. LEACHING CHAMBERS: P.R. < 2 MIN/IN CLASS I \ \! \\ BENCHMARK \� _ \\ I (10 MIN) \ 1 I I USE: 1 -12' WIDE x 60' LONG x 2' DEEP LEACHING CHAMBER SYSTEM PROPOSED 1 \ 1 � FLAG POLE BASF ELEY-97.8,3 ���, / ADDITION �, ` W\ 7-PRECAST CONCRETE LEACHING CHAMBERS SILL EL=98.88 18.3 , V ! \ 1 TITLE V g�UE srONE f �� PROPOSED AREA: 7x8 +4+1 x 3x4 +1 793 S.F. 1 ti 1500 GALLON O PATIO [( {61 ] x [C [1] ] = 793 S.F. 1 !\ �� \y SEPTIC TANK ! I EX/ST1,,NG DWZ-ZZ/NG CAPACITY: 793 S.F. x 0.74 GPD S.F. = 586 > 550 GPD D.D.F. 1 I / C ) I \ �� ! SILL ELEV 98.88 "' � rRELL's \ SEPTIC NOTES ►.� 108.3'f 20'MIN \ \ I II Q,`'�c� , EXISTING 0 \ 1 I ! #,9 GARAGE \ 1- 60' LONG x 12' WIDE x 2' DEEP I �v� / i SLAB EL I 1. PROPERTYLINE DATA FROM BARNSTABLE COUNTY LAND COURT PLAN 5725-18 DATED MAY 14, 1970 \ \ LEACHING CHAMBER SYSTEM W\ 7- I I I =98,4i \ I PORCH I •\ q �. PRECAST CONCRETE LEACHING CHAMBERS I10' ----- 2.+ 2. TOPOGRAPHIC SURVEY BY GRADY CONSULTING DECEMBER 4,1998 \ � �}� � � fig - - - - - - - -i~ H \ �� gRFA 6 4 2� LAG \ '=r 3. SOILS TESTING BY GRADY CONSULTING WITNESSED BY JERRY DUNNING DECEMBER 3, 1998 Q POLE 4. CALL DIG SAFE 1-888-344-7233 AT LEAST 4 DAYS PRIOR TO COMMENCEMENT OF CONSTRUCTION. �" cHr / 0� \� �- Ji � 5. NOTIFY TOWN AND GRADY CONSULTING PRIOR TO BACKFILLING OF SYSTEM. U \ 82 \ \ POLE. I 0 \ \ \ / I �•y o \ \ --- -- __ �, LEGEND ,� 0 ►� EXISTING PROPOSED x J \ I I I I J - - - - - - - -1Q1 - - - - - - - Co 1 CONTOUR 100 � E®+ r� w 99.8 SPOT ELEVATION +100.50 Q n o- o i �{ I 1 \ PROPERTY LINE / I i - ` N _.. EDGE OF PAVEMENT O —W— — — WATER LINE W �r TEST HOLE � / I Q I / / I h / f tit t 4 ,7 J. LADY ilk °FrR�s SOIL LOGS h� LARGE CONFER j T.H.#1 R MAP 119 LOT 58 I %� U EL. 89.48 ASSESSORS I LARGE DEGD OUS DECEMBER 7, 1998 118,646± S. F. I � 1 O'AB4" ,. _ BND s , SCALE: 1 - 20 '' i / �,, / / / / I ,' ■(fnd) o ROLL Y TRE, SANDY LOAM 87.48 I I 'W JOB NO. 98-065 8>� / PERC />� SMALL CONFER LATEST REVISION: BND 1' 24"-120" 21-6" (fnd) , �� \ SMALL DECDUOUS C P.R.<2 _..._ SAND MIN\IN 1 — _ — --R 15_ _ / ` RANDOM B�1SH & BUSH ROWS/ 9 ,E— S15 2 -a= f--- — --I 79.48 I ISTREET D=10'-O" MAINI — \ 20 0 20 40 60 NO WATER \21 I m M C', -- -- ` _61/yo Seale 1 " _ 20' 0D --- — --- --- — — ____ , ___._ --- SHEET 1 OF 1