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Home My WebLink About0031 IPSWICH CIRCLE - Health 31 IPSWICH CIRCLE, OSTERVILLE �I fl No.••••••••....•••--.....-- Fmc.............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH . ----------------------------------- Application for Uiivuuaal Works Tom5trurtivat Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at .ems -79;sty 4 ........ �. ................. :�! •... Cc e ,. ) oca o -Address ._`n�`® ey q D--------------•------•--••--.------.... .......13.E ,S.P.f:. 6-�"',�l'.�.. t<42A -l-ki w Owiier Address a ....... .. .................. Installer Address Type of Building Size Lot." ..�• ......Sq. feet Dwelling—No. of Bedrooms___.........3...........................Expansion Attic (V10) Garbage Grinder 4o �'4 Other—Type T e of Building ............... No. of ersons.........._.._........_.____ Showers YP g ------------- P ( ) — Cafeteria ( ) Otherfixtures ------------------------------------------------------••---••••••--•--•--•••--••-•----- w Design Flow......m........ .............gallons per person per day. Total daily flow_....10............................gallons. �^ If �� j t W Septic Tank—Liquid capacity.1QQOgallons Length.""..__ Width.. }..--S _- Diameter________________ Depth..._.&.' x Disposal Trench—No..................... Width.................... Total Length..._....._.......... Total leaching area....................sq. ft. Seepage Pit NO...___----I---------- Diameter.__...6.......... Depth below inlet......0.......... Total leaching area.'ZQ_0......sq. ft. Z Other Distribution box (Y65 Dosin tank (0� '-' Percolation Test Results Performed b -_ PsK_ _ ,v�� L.................. a Y --------- -- --- Date-- Test Pit No. 1.... :_..minutes per inch Depth of Test Pit.._V......._... Depth to ground water. b_T' i1Qt�rc -(L�� fs, Test Pit No. 2_. -_-_minutes per inch Depth of Test Pit_.10........... Depth to ground water_&0"05 ePW, 04 •-•-••••-•••---------------------....---......S•--•--•--•----•--•-•--•-----•......--•---•••--.--•.................•....................................... xDescription of Soil... ".�..u.._ u 2-1A(�•w!,..4-.m_ - ..�C°.Q_ .�5i�!-�4�__-7::'1.0.. i }� U ._. -� ®.m` d0!� --------C c�..2-�. .....COAe�----..... ....................-...................-................... w V Nature of Repairs or Alterations—Answer when applicable....__.......................................................................................... ---------------------------------------------------------------------------------------------------------------------- ..........-....................-..............-...................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accpr4ance with the provisions of'THE 5 of the State Sanitary Code—.The undersigned furti:er agrees not h system in operation until a Certificate of Compliance has been sued/b�y the board of healt ned.. !.f ................. -------- ------------- ---- - D e ApplicationApproved BY-••-•-----•••••••--•••--Q...............•--••----•-•.....•... - ................... e. Date Application Disapproved for the following reasons:-........................................----...... ............ ............................... ..............•...............................................................................................................................................................................---•-----•- Date Permit No.•••••8 2------Z Q-3------------• Issued----------C-- --- ai -- -- - -------------•---- LG No...S ...."�� Fus.....'.::- .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF t .� .✓_�..:=- . l' ... Applirta#ivat for Uhipoii ai Works Tmuitrurtivat Prruat Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: /y{�� f ...-.}^.7 1it::�_E 8... ... j Z:( .._._...... -w_T4wZ V i..':: ................. _1...` f 10;,_ 4ti"'�'V 4 r-•S-'d.: t; ...... acayop'-Address �p�/!' St. 0 .��;i1�........ ..................... ... Owner Address W Installer Address Type of Building Size Lot_�Z�..A`tom:1......Sq. feet Dwelling—No. of Bedrooms............�............................Expansion Attic NO) Garbage Grinder (4 t) `4 Other—T e of Building No. of persons............................ Showers I — Cafeteria dOther fixtures .----•-----•-------------------•----•--..--•-•--....__.......------........._..__.._._.._....-•---•---••--------•----•-•---••---------.._....---•----- W Design Flow................ .:?.....................gallons per person per day. Total daily flow--_-----Cl!(........_....................gallons. W Septic Tank—Liquid capacity 5 V)__gallons Length Ems'-L_... Width.44`-�( _. Diameter_ ... iameter............... x Disposal Trench—No. .................... Midth.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No.................... Diameter.._... .......... Depth below inlet.....62_.......... Total leaching area:?-.0_C)......sq. ft. Other Distribution box Dosing tank Q t ~' Percolation Test Results_ Performed by._-�?:�K_ f f ______.'( ......... ................... Test Pit No. I-_-Z..�.....minutes per inch Depth of Test Pit....1,2........... Depth to ground Test Pit No. 2__4. '....niinutes per inch Depth of Test Pit---).o_........... Depth to ground �O♦ Dseescription of Soil.-._, .._+ ... %`._'<...4�- c. �'�- '.--'�'...-`-=' `c-�-----fie '"fl _..t..�� -a7K7 r„C,•8 tip...---- -� w 4 i cJ" � d. 5Ea.t c ✓�+...i i `,yr,5 'L,,.; i t (,,,Y .{3, .,�'".•r". t L1 h,..3.._ '---- U W -------•--------------------•---........_............._..---------..._...._........._._......_.......__.._.__._....._..............__............._....._.._......_..._.._......._......._.._._...._.... UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT E 5 of the State Sanitary Code—The undersigned further agrees no�to �he system in operation until a Certificate of Compliance has been 'ssued by the board of healt �i-- - Z p`�.... r ----•----- --- D e , ApplicationApproved ...........................................f!... .......................... .........V--- atete Application Disapproved for the following reasons--------------------------------•---------••--•-•••--•--.._.........--•-••......---•-•......................... --------------•---....---....---------•------•--•-------------....--••--•-----•-------------------...-•---••-----•----•-•--••-•••••••••••-•----••-••••-•-••--.•••-•-----••......•--••-•-----••••••----•- Date Permit No........ :.,� �. ............. Issued......... '2_. ?,(.�F'......---•--•-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Trrtif iratr of Tuutpfiana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repairedby ( ) .........................•--.......---------•------------------•------•.-----------..........----...-•----•-•------....---....-•--••-•---------•------------•---•----- Installer� .............` ` �~ - � 0atj has been installed in accordance with the provisions of TITIE 5 of he State Sanitary Code as describFd in the . f application for Disposal Works Construction Permit No...... �_.... -.a-�.-_.... dated-.-.._-_ .'y! . _ti?Q.-.-.•- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. ....a'. .'... •/ ..... ---•-•-----_. Inspector.. ........................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... a......OF. { .kx: ...................... l .. No.....�':�, ... � FEE ...................... �iu�uu�a1 urk� C�uatu�ruan rruti# Permissionis hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ) qn Individual Sewage Disposalt System at No.......... �"' ,r� �Jit#�C 21 7i-------------� -1 t C. ---- Street as shown on the application for Disposal Works Construction Permit No ��_...=d ated_.__ -•----------------------•-......-•••-~' DATE..............CR - '` �� Board of Health ------•--• --------- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS Jukie-Z7, I �►� VC 20/ to/ to I Lc. 3 t$73$ ,6+kear 1 t� MAP tG5 Lar 5-1 Z 9® g7 I - n -?2. ran 4Z %�NYo cuc�l-4 cP1 Ipg� � 98 8•� ZIP �' Y P �ssuk�:.p , i C� '�5 '^'q1• .1 a w i oo.o i °A `90 't'wac P 7c3,jso FC id �SEaTIG ! I Low18l►�EO TN I � Mw tA�tu\ I 22�\11 V75 F I i 1' a3 5A' leelv j N �f Yqj . .� PfTER31 18,. SULLIVAN `~ No. 29133 ONAL Eh�' FiICA. FWP+O `yam �S�'Et�V I C.t� `^ CTER H hNo.2 ,X�t .� `(C 1 N C �A �ECislE��o �° "K�Ect ST�CC`7i t.AtitD -6UO l4el<OeS Iu Fee s • 1 DESI C-211-DATA 1./2 R' -� 511JEiLE I-Aty()L�(- 3'f3�p�t+t5 Ala G-rat::a � G ttau�>r: FC��t tr i Z/2 VA 1 t_�( r=Laic,/ : t l D x 3 a 33D�6YD SEP•'TIG�hiJ�C. % 33D ��saX: g956�4'� Il Dis'Po5ALPrr, use )Ocx> ErAi 1,.Ot,-ITT ,,•, " fit{ OF Pit v�l c'n-I 1' G Qtj S{-F G'i7 STO l�I'� .�•��P,,�'� rytq��.'• t��F'� '��`',y�� S it7E v1h1..�- " e�' `, P.C.TE R l ��ICHiRb �y AZF-A, v mo sr- A. SULLIVAN PA4a-1:�sos F C2,6 = 3Z564�i }� BAXTER (n No. [ Crk 9733 SEC/STEREO`Qy� ', 6 %Ll* Is-Fy'� + 1'aTq►... -R Et5 t br�! 1=�.o u.,/: 425 6c�'7 � , —'1 e>�Ga1,p.T1aNT�hT� 1'V�o9 !N 2Mt�►1.aeLs55 T•E5T N oLr, 1�- 725C6 o 'Toy aF Ft`1t7 r�. fbao 3G 0 1007D ySo ox -V CTtiJ_ INN/s � l� 4 (S-�. ` Rrr I V Tf.uK ��D ° 3q roll H C ERTIFI ED pI--OT RAN s-►au� EL 09,v I-OoATON: -7, ')F Et_85,b Fos eosit r.> I C.�K-C'1 F`f -CI-1 Pc`T'T4•E E.�o�►aa�-n o►�l 'S H taw N ANIQ '6F-�Ate—K -KE6xl%F-EMlG7NT5 >Aeu:S-r�ya>C� AU-0 is I.\ - i_Z>fA`T i W t TI-411J -rH E -F I...aUI m Lhl J.L. TH i 5 l�A►� 15 NOT A 5 E T� o N A N I N ST R t1 M NT 5UKYEY AND T HI= 0FF5ET5 5HOWN 5WO4L-D Ig4>T ACC �' J 13E US ETA TIC EST&73L1SN Lz;;;-f• L)NE5. @,Ca2o1 e, � Commonwealth of Massachusetts Executive Office of Enviroranental Affairs Dept. of Environmental Protection IN Jolui G><;>tci One winter Street,Boston,Ma. 02108 D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 ,,(508)564-6813 WILLIAM F.WELD Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �Lt. PART A - CERTIFICATION Al 2 6 1999 Property Address: 31 IPSWICH CIRCLE OSTERVILLE LOT 79+80 Address of Owner: Date of Inspection: 1/7/99 (If different) Name of Inspector: JOHN GRACI SHARON BRADOCK;BOX 503 OSTERVILLE MAP 02635 1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) 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 P855e5 This Inspection Is based on criteria defined In Title V code 310 CMR 16.303.My findings are of how the system is _ Conditi Wally Passes performing atthe time of the inspection.My inspection does Need ur er Evaluation By the Local Approving Authority. septic y any temanwarranty ortscom guarantee ne the longevitysusefullife.of the septic system end any of Its components useful life. Fails Inspector's Signature: Date: 118199 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)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: B] 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 CdMpliance(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 04127)97) -5500 One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 a Telephone(617)292 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION (continued) Property Add re SS: 31 IPSWICH CIRCLE OSTERVILLE LOT 79490 Owner: SHARON BRADOCK;BOX 503 OSTERVILLE MAP 02635 Date of Inspection:117199 _ Sew.aae backup or.breakout or high.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. 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 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. , _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. )revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 31 IPSWICH CIRCLE OSTERVILLE LOT 79*80 Owner: SHARON BRADOCK;BOX 503 OSTERVILLE MAP 02635 Date of Inspection:117199 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 ma 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 II 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. {revised 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST r Property Address: 31 IPSWICH CIRCLE OSTERVILLE LOT 79+90 a; Owner: SHARON BRADOCK;BOX 503 OSTERVILLE MAP 02635 Date of Inspection:117199 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. a 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. a 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. , _x_ — 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. �t I 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. r x Existing information. Ex. Plan at B.O.H. Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is x — — unacceptable)[15.302(3)(b)1 rt (revised 04127197) + SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 31 IPSWICH CIRCLE OSTERVILLE LOT 79+90 Owner: SHARON BRADOCK;BOX 503 OSTERVILLE MAP 02635 Date of Inspection:117199 FLOW CONDITIONS RESIDENTIAL: P d./bedroom for 5.A.5. Design flow: 330 9• Number of bedrooms: 3 Number of current residents: 3 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Ye: Seasonal use(yes or no): No Water meter readings,if available:(Iast two(2)year usage(gpd): nla Sump Pump(yes or no): No Last date of occupancy: nla COMMERCIAL/INDUSTRIAL: Type of establishment: nia 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) Na Water meter readings,if available: nia Last date of occupancy: nra OTHER:(Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM WAS LAST PUMPED BY CAPELAND System pumped as part of inspection:(yes or no)Ye: If yes,volume pumped: 1500 gallons Reason for pumping: MAINTENANCE TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool k 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? Other: APPROXIMATE AGE of all components,date Installed(if known)and source information: SYTSTEM IS 9.6 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no) No (revised 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 31 1PSWICH CIRCLE OSTERVILLE LOT 79+80 Owner: SHARON BRADOCK;BOX 503 OSTERVILLE MAP 02635 Date of Inspection:117199 SEPTIC TANK: x (locate on site plan) Depth below grade: 2' Material of construction:x concreate_metal_FRP_Polyethylene_other(explain) If tank is metal, list age nla . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L9'6"H5'7"w4'1O" Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle: 31" Scum thickness:3" Distance from top of scum to top of outlet tee or baffle:S" Distance form bottom of scum to bottom of outlet tee or baffle: 15" How dimensions were determined: MEASURED Comments: (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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM FOR MAINTENANCE EVERY ONE TO Two YEARS. GREASE TRAP: (locate on site plan) Depth below grade: Na lene Pol lain Polyethylene_other ex Material of construction: _concrete_metal_FRP_ y y other(explain ) Dimensions: Na Scum thickness:Na Distance from top of scum to top of outlet tee or baffle:Na Distance from bottom of scum to bottom of outlet tee or baffle:Na Date of last pumpingrila Comments: (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.) , a • BUILDING SEWER: (Locate on site plan) Depth below grade: 2'6" Material of construction:_cast iron x 40 PVC_other(explain} Distance from private water supply well or suction line•rowN Diameter. Na_ rwomments: (conditions of joints,venting,evidence of leakage, etc.) " trevlaed OQ1197I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 31 IPSWICH CIRCLE OSTERVILLE LOT 79+80 Owner: SHARON BRADOCK;BOX 503 OSTERVILLE MAP 02635 Date of Inspection:117199 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda Material of construction:_concrete_metal_FRP_Polyethylene—other(explain) Dimensions: nra Capacity: nra gallons Design flow: rya gallons/day Alarm level:_n1a Alarm in working order?_Yes_No Date of previous pumping: Comments: R (condition of inlet tee,condition of alarm and float switches,etc.) nra DISTRIBUTION BOX: x (locate on site plan) 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.) rda PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)No T Alarms in working order(yes or no)_ve: Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) nra (reylsed 0412A97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 31 IPSWICH CIRCLE OSTERVILLE LOT 79+80 Owner: SHARON BRADOCK;BOX 503 OSTERVILLE MAP 02635 Date of Inspection:117199 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: Na Type: leaching pits, number: 1 ODD GALLON LEACH PIT _ leaching chambers,number:Na leaching galleries,number: Na leaching trenches,number,length: Na leaching fields,number, dimensions:Na overflow cesspool, number:Ne Alternate system: Na Name of Technology:_Na Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY.THE PIT HAD 16"OF LEACHING LEFT AT THE TIME OF THE INSPECTION. CESSPOOLS: (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: Na Depth of solids layer: Na Depth of scum layer: Na Dimensions of cesspool: nla Materials of construction: Na Indication of groundwater: rda inflow(cesspool must be pumped as part of inspection) Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Na i PRIVY:_ (locate on site plan) Materials of construction: Na Dimensions: Na Depth of solids: Na - Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.). Na (revleed 04127)97) TOWN OF BARNSTABLE -..LOCATION47 l�` C� ��S'�ii�� Ce 2��EWAGE # 0. d VILLAGE. (�� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. /V ✓S 7- SEPTIC TANK CAPACITY cad G 0 �3 LEACHING FACILITY:(type)ACA s�" /�1 i (size), NO. OF BEDROOMS —3 PRIVATE WELL OR PUBLIC WATER ,"'u BUILDER R DATE PERMIT ISSUED: !J DATE COMPLIANCE ISSUED: Ef VARIANCE GRANTED: Yes __No � __�� ,�, �-�' l 3 G � � 3 � .� .. , .� �� t j _ �� " :v l��S'u✓ iG �. 2C' /tom - - - _ � LOCATION SEWAGE PERMIT . NO. Lot* k 3 12Stuiet-f VILLAGE TE/9 L), L t-c- INSTA LLER'S NAME A ADDRESS Lo � B U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � � �(e� �� o�� SC � � � � �� -,.. _ __ t: TOWN OF BPARNSTABLE LOCATION ` °'� SEWAGE# VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. i SEPTIC TANK CAPACITY I LEACHING FACILITY: (type) I��..�f.�f (2 1" (size) l NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 facili - Feet Furnished by ,. _� i r� � ... o " .; �{..: �, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 31 IPSWICH CIRCLE OSTERVILLE LOT 79+80 SHARON BRADOCK;BOX 503 OSTERVILLE MAP 02635 1/7199 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� a- Pape ! of 10 (revmed afm197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART C SYSTEM INFORMATION(continued) 31 IPSMIICH CIRCLE OSTERVILLE LOT 79+80 SHARON BRADOCK;BOX 503 OSTERVILLE MAP 02635 1R199 Depth of groundwater 12« Please indicate all the methods used to determine High Groundwater Elevation: i 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 CHARTS H (revised04)27197) rave 10 of 10