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Home My WebLink About0105 ICE VALLEY ROAD - Health 105 Ice Valley Road, A= 096-018 Osterville Fee No. Or — �U y � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Disposal *pstrm Construction permit Application for a Permit to Construct( ) Repair(111<91ade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.10g Z-CC41o1_LE!1/Z.W-D Owner's Name,Address an e os - Fa �rccE �� 01 cscxTr o� Assessor s Map/Parcel Instal s Name,kddress,and Tel.No. Designer's Name,Address,and Tel.No. IVA �v�/7�3 Type of Building:g: P 1-Y Dwelling No.of Bedrooms dV Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil AV Nature of Repai s or Alterations(Answer when applicable) ai2 _ (/_' ,e p Y C D 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 an not to place the system in operation until a Certificate of Compliance has been issued by this Board of H Signed Date Application Approved by Date -7h i Application Disapproved by Date for the following reasons Permit No. ( � 2 3 —7 Date Issued 2 J No. — e7 Fee THE.COMMONWEALTH OF MASSACHUSETTS Entered in computer: L PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es 4plication for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(grade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No./Os Z-G Owner's Name,Address an Te N.. 0or's r_Map Ass /Pa�rCel L E D�� ( �SGdB Tr �J� �Jf�d�s� � Installs 's Name, �ddress,and Tel.No. Designer's Name,Address,and Tel.No. I r Type of Building: Dwelling No.of Bedrooms Lot Size V sq. t t Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs [L or Alterations(Answer when applicable) /? ��C% �F>p rT r n Date last inspected: /,Q 0 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 an not to place the system in operation until a Certificate of Compliance has been issued by this Board of H Signed Date Application Approved by f Date i / Application Disapproved by Date / for the following reasons Permit No. ;?-U f —— 2 3 Date Issued THE COMMONWEALTH OF MASS AC'�SETTS f BARNSTABLE,MASSACHUSETTS Certificate of Compliance J THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by LI.Zz ,e1 at /n.�� Jt=// GL tF' �°'�7�/}G� has been constructed in accordance l with the provisions f Title 5 and th isposal System Construction Permit No date 7/�/ f Installer zw — Designer #bedrooms ►��/1 ^� Approved design floe gpd I � � The issuance of this permit shall not be construed as a guarantee that the system w'll`fun`stion as designed. Date I 2 Inspector a --------------------------"-�---------------------------------------------------------------------------------_-------------------------- No. ( � ! Fee /44.1 le THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS MispoBat 6pstem ConstrUrtion permit r Permission is hereby granted to Construct( ) Repair(L4' Upgrade( ) Abandon( ) System located at l 6 5' C" 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 m t be completed within three years of the date of this permit. Ol Date —7/1 1 If Approved by /� AsBuilt Page 1 of 1 -I O LOCkUON SE AGE PERMIT NO. t„ V1LlAGE n ftSff V) �/1M Y.��+14 STALLER'S RAW i ADDRESS bd / U I DER OR OWN E DATE PERMI ISSUED U. DATE COMPLIANCE ISSUED r46�' 1 . " r http://issgl2/intranet/propdata/prebuilt.aspx?mappar=096018&seq=1 7/21/2015 r_1a� Commonwealth of Massachusetts plg Title 5 Official Inspection Form p, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments S )b Q N 1 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name/ information is �/ required for every Osterville Ma 02655 5-28-15 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. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew F. Gilfoy use the return Name of Inspector key. B&B Excavation Q Company Name . 14 Teaberry Lane Company Address I Sandwich Ma. 02644 CityTrown State Zip Code (508)477-0653 S113640 Telephone Number License Number - B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5-28-15 inspector's Sickature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name information is required for every Osterville Ma 02655 5-28-15 page. City(rown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for°yes", "no" or"not determined" (Y,_N, ND)for the following statements. If"not determined," please explain: The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): l5ins•3/13 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 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name information is required for every Osterville Ma 02655 5-28-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): D-box in poor condition with sand falling in through cracks. D-box must be replaced. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety-or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name information is required for every Osterville Ma 02655 5-28-15 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes 'No El ® 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 El ® due to an overloaded or clogged SAS or cesspool El ® 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 El. ® than '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name information is required for every Osterville Ma 02655 5-28-15 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ® 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 well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. . t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name information is required for every Osterville Ma 02655 5-28-15 page. City(rown 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 ❑ E Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 i t5ins•3113 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 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name information is required for every Osterville Ma 02655 5-28-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected?. ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gp ))� Detail 2013-460 000gallons (1260gpd) 2014-610,000 (1671gpd) Sump pump? ❑ Yes ® No Last date of occupancy: Date ear ago Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins-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 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name information is required for every Osterville Ma 02655 5-28-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): - General Information Pumping Records: Source of information: unknown last pump Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name - information is required for every Osteryille Ma 02655 5-28-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1982 Were sewage odors detected when arriving at the site? ❑ Yes Z No Building Sewer(locate on site plan): 1,8„ Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank (locate on site plan): 101, Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon 6„ Sludge depth: t5ins•3113 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name information is required for every Osterville Ma 02655 .5-28-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.)- At time of inspection septic tank appeared to be in working order,Tees present no sign of back- up.Liquid level equal with outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness < Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping:- Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name information is required for every Osterville Ma 02655 5-28-15 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: . gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑. No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , ' 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name information is required for every Osterville Ma 02655 5-28-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): . At time of inspection d-box was in.poor condition. D-box must be replaced. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. .Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 F / Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , ' 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name information is required for every Osterville Ma 02655 5-28-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-6'x4' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Pit#1 was dry and pit#2 had 1' of standing water at time of inspection: Cesspools (cesspool must be pumped as part of inspection) (locate.on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form: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 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name information is required for every Osterville Ma 02655 5-28-15 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 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 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name information is required for every Ostelyille Ma 02655 5-28-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a-view of the sewage disposal system, including ties to at least two permanent reference landmarks or"benchmarks: Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below -drawing attached separately of no A O O a .A 31,yt, A3- 391 A 4 - 56t —3(o' �y -35'y It t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name information is required for every Osterville Ma 02655 5-28-15 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water No Gw 6' below system feet Please indicate all methods used to determine the high groundwater elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1-19-83 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with Iocal'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: Plan of file at BOH 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 .' 105 Ice Valley Road Property Address Estate of Martha Segur Owner Owner's Name information is required for every Osterville Ma 02655 5-28-15 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 4 1 rr L TALLER'S 4,A ME ADDRESS L - Ul DER OR ow i , � � nr Iq Ire- >' '• �� .o� Fps.... No.._. .Py.. - .. ............... THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALTH y I �.Ok?hl.--_................OF..�AP.�.0`�� 4.��----•---•--- 1 Appliratiou for Bispos al .arkii Tilmitrurtion amit Application is hereby made for a Permit to Construct ( � or Repair ( ) an Individual Sewage Disposal System at: ......--•-----•-•----•--•.... - ...............................( ( -----------------------------------------/r .......-- ... .. . . .. - Location-Address or Lot No. • ._._..... F., If ............. .............. owner Address _ __••- _• Y'uilding oile ___-_ ........_..................._ _...._.. __--_�Installer AddressType of �/ Size Lot.__.. U Dwelling—No. of Bedrooms.__........_-.4..._..•.•...............Expansion Attic ( ) Garbage Grinder ( ) Other-T e of Building No. of persons............................ Showers — Cafeteria Other fixtures WDesign Flow..................... 5........." -..gallons per person per day. Total daily flow..__...............__........_gallons. WSeptic Tank—Liquid ca.pacityl�Ql1-gallons Length................ Width................ Diameter................ Depth................ xDisposal Trench—No.-••-•----.•-.--._._-_ Width.....,..:.......... Total Length..............t.._.__ Total leaching area....................sq. ft. Seepage Pit No----------I_.._..-__.• iameter........ __..... Depth below inlet......Z.......... Total leaching area.....dad.sq. ft. Other Distribution box ( • Dosing tank ( ) //' A JOB P�, �_g_03 a Percolation Test Result Performed by..tJ- XT0,_ -----t-.._-•---••-f-f-----lZ-p...----•-•--------- Date--------------------- --------•--- ,� Test Pit No. 1........__ minutes per inch Depth of Test Pit........1•••-...... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------•-------------------------------------------••-•---••-----•-•-----------•--•-----•------......................................................... Description of Soil---------------------- ---- -- .............. W •-••-•----••---- ,: ::_- <::=: -------------------- --------------------------------------------------------------------- ..................................................... UNature of Repairs or Alterations—Answer when applicable.-------------------------•..................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordant the provisions of iI:E 5 of the State Sanitar Code— The undersigned further agrees not to place the- operation until a Certificate of Complia e has i e yithe board df health. Sig Application Approved By... •-• ( ' . . .••••--•...-••.....••-••-••--•-•--•-•-•-•-•--••..............•..__.._. Application Disapproved or he following reasons:..................................................... ----------------------------•---••----------•--•-•-------------------------•----......-•--•--•-----•-•- •----•--••-•............•-- PermitNo.........................-------------------------------- NFu$.... �............... THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH . .........................OF... '.�:fJ T, .?� (-" .................................. Appliratiou for 3lispoiial Workii T000trurtiou ramit Application is hereby made for a Permit to Construct ( r) or Repair ( ) an Individual Sewage Disposal System at: ...........................I........ 12 e!.W.n W. Location-Address or Lot No. — l N,� '= L?.u. ru _! ........................... Owner • Address :rdiXl/��.:4.ec ....................................................•........ Address dType of ding Installer Sze Lot___3 U Dwelling—No. of Bedrooms___........ .........................Expansion Attic ( ) Garbage Grinder ( ) ............... No. of ersons......_...........__.__.____ Showers — Cafeteria Other—Type of Building ............. p ( ) ( ) Q' Other fixtures WDesign' Flow.....................� .._...._.__..gallons-per person per day. Total daily flow........................ _.__.._v`�_._.....gallons. WSeptic Tank—Liquid'capacity .G4 .gallons Length.............. Width---:............ Diameter................. Depth................ x Disposal Trench—No. ................... Width...... --:.......... Total Length.............*_..... Total.leaching area....................sq. ft. Seepage Pit No_______ iameter........6-___- Depth below inlet............... Total leaching area..... .sq. ft. z Other Distribution box (;e Dosing-tank ( ) Percolation Test Result Performed by._ _ 4��_ Y�.._.... -_:d-6pts...Rie..... Date...1' �>" ' ................. Test Pit No. 1................minutes per inch Depth of Test Pit-------- ....._ Depth to ground water------ "'_____--__-_-. f. Test Pit.No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----•------ . ----------------------------- ..... •-------------------- .------ •...... ----... •---------- ... •----------------------------------------- •-- O Description of Soil........................... ..................:........ t, ------------------------ W ---------------------------•---------------------------------•-•-------•---------•----•-•••-•-••-•------------•----------•-----------•-•----•---•----------•------...-•----•-•-••-•-•-•---•----•---••--- U .Nature of Repairs or Alterations—Answer when applicable...__........................................................................................... ------------------------ •---•-........._.-•--••--•----•••-----•------------••---•--•--•••---••--••---••-----•-•--------•-•---------•-•-•-------•-----•-------........................................ Agreement: The undersigned agrees to install the-,zaforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitar Code— The undersigned further agrees not to place the system in operation until a Certificate of Complia e has i ued ley the board df health. „u Sigd ------------•-------------•-----•-•-•--•...•---•_.••... ...I. . •. ...5._3 Application Approved By .... �--------------------•-•-•----•-•-•-----•---------------------•-----. ...........-•------ Date Application Disapprovediing reasons: = D --------------------•---.....--------.....:-----••----------•-------------•------•-------....------------'---•-•---------------------------------------------------------------------------------••--•--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,t Tntifiratr of Tomphaurr TS TE TI That the d vldual wage•Disposal System constr cted ( or Repaired ( ) by.. .... � . rc......••. . ----------------------------•--•-••------....---- -------- --- In al " " at..__.. .._.. l._.......__�......... ..... _._. _. wl� '.__ _.. .._..-_.................." ----.. .................................... . ... .. has been installed in accordance witti'tl r visions of TIC F >` o he tate Sanitar Co ass,S� cribed in the p ��-------•=..... dated_/ .... ��application for Disposal Works Construct n Permit No_____________•__._.__ __.___....._...__..... THE ISSUA, C F THIS CERTIFICATE SHALL NOT BE CONST S A GUARANTEE THAT THE SYSTEM WiL F CTION SATISFACTORY. 77�DATE...Z -•-z -- ....................................................... Inspector.. .... ...---------•-••-------••---•------•----•---•---.......------•---•--•--- THE COMMONWEALTH OF MASSACHUSETTS a BOARD OF HEALTH ........OF........ / I•� .4r -------------------•----•-...............Taw.14 .......... No. FEE........................ B r io ork tr ion ,� . ft Permission is hereby gran a -- --------•---- . . .•-----. - ... ... ........ ............................. :� to Cons tr or air ) an u ew posal System at No.. ------ ...------ """ Street as shown on the applicatiorl�for Disposal W Construction Permit .No........... ...... atedl .................................... ,•; 1F/' V J. .......................... 1....____................................................................ T Boar of Health DATE -------••------•-•-•-------•••_.....f....-•---•----•-. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ASSESSORS MAP NO;....,_,_,,�_ .sir- �7 PARCEL N0�_.... Q _,_._.,_ NFee---= o.- - - - BOARD OF HEALTH TOWN OF BARNSTABLE Application-for Vell Conoructionj3ermit Application is hereby made for a permit to Construct (✓), Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel //�� // Owner Address _D AE4jx'"�''-tP`!----------------------------------- L•_o. /v oX 6 /4 S�, 9 a�-�c ----------------- -- -- --------------------------------------------- ------------------------------------- Installer — Driller Address Type of Building Dwelling---------------------------------------------------------------- Other - Type of Building ------ No. of Persons----------------------------------------------------- Type of Well ,�--———---- Capacity ---— - - — — --- Purpose of Well ��_° r?a_^�-------"'l,'----------------- 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 until a Certificate .00f C mpliance has been issued by the Board'of Health. Signed =— - -- - ------- — ----PAYS ) - -- date V 4- Application Approved B - -- -—-- --- -— --- -----=5t---r, date Application Disapproved for the following reasons:-------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------- date Permit No. - � r -------- Issued-- �-- -- ----- — - — date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( �, Altered ( ), or Repaired ( ) by------------ �.��T � __------------------------------------------------------------------------------------------------------------ -------- Installer e ——--- ------------------------------------------------------------------------------------------------ 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!�'-' I Z4- Dated/ �V f 7 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------- ------ — - ----- Inspector-------------------------------------------— - ------------ 4b Fee--- �[------- --- No. ! y BOARD OF HEALTH y TOWN OF BARN-STABLE /Application-*rWell Contruction emit �l�; Application is heie/b/y ma enfor a 4.e nitlto /af�lsfruct (✓), Alter( ), or epair ( )an individual Well at: - -- --- ------ els--— - -- — •- --_ - --_-- -- -- I-Lion Address' Assessors Ma and Parcel P el �_4✓v— t'to U r--------- ---------- -----— --— t D —��=- ------ OwnerC°I4O t ---------------- Addresss f r P l /c� /4 S Q ---- - - ----------------- Installer — Driller j Address 1 Type of Building Y Dwelling--------------------- Other - Type of Building--- ------------------ No. of� rsons-----------------------= - 1 Type of Well ;-- - -- - --- - �ap,!city----------- Purpose of Well �l_�= �7�?a -E Q"1,'- - ------ Agreement: The undersigned agrees to in tall 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 t\ place the well in operation until Certificate .of C mpliance has been issued by the Board of Health. 2 Signed �_ -- - -- - ------- - - �YL -- -- date Application Approved B - --------- - --- - '� �G �! "�%"7 date IApplication Disapproved for th following reasons:-------------------:-------------------- ------------------------------------------- --------- date Permit No. -�� - -� --- - — Issued date BOARD OF HEALTH TOWN OF BARNSTABLE 1 Certificate Of Compliance THIS IS TO CERTIFY, That the Ind ' al Well Constructed ( 'f, Altered ( ), or Repaired ( ) by----------—- �1�=�11 un�+"� u -7----------------------------------------------------------------------------------------------------------------------- Installer P / I has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection ,4 Regulation as described in the application for Well Construction Permit N . ---------`-' -XDated ZV f;;;' ol THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- ---- ----- - ------ -- Inspector----------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE ` Writ Cootruct ion permit I No. �'/�___� � Fee-- ----'`'J LU ww e l� Permissionis hereby granted- - ------------------------------------------------------------------------------------------ to Construct (,--I; Alter ( ) or Repair ( )an Individual Well at: !. N o. 1 ---/C e - ��G - ==-- ------------------------- Street as showli on th ap lication for a Well Construction Permit No. - _ �- --- — - - Dated---`� G �- �----- Board of Health DATE—� --� — - i t S L2v� i '= t1 USt i�ace �L ►'��c,i�:.. goo L W %! �' sTaJE S3 x z S 1307ro.A A L_Ea1 S.F . I00 SF K 1 •o - !v r_) & ? D. TOTQ L ` >e 161! RM F r�-v 4�; Tj �o V Ta'P G'F SIG �! 21 �1 aG ; 7sp�> _4j \ \ o� h m r' CD a4 (,, I � L r i r<.b�• 'irk J I 1 T , - Rai c � _' ----_ --------- rl St)�i01 K! 1 ✓ -I TA iL P`Ts. w 1" rL �n►U a<_i. ,c, i G - 5 • 'w N4-17�' +• - -- t 4V;- .t i�. 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