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HomeMy WebLinkAbout0011 JANES WAY - Health 11 Jane_S,Way Osterville A= 146—049 TOWN OF BARNSTABLE LOCATION -Tc v e% W a,/ SE4V*6 E `VILLAGE ASSESSOR'S MAP&PARCEL INgPiEE-PrS NAME&PHONE NO. i�,�Ll� �Or)K t,t SEPTIC TANK CAPACITY QCaD LEACHING FACILITY.(type) (size) NO.OF BEDROOMS OWNER oc LAQ- PERMIT DATE: CO ATE, 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 lands exist within 300 feet of leaching facility) Feet FURNISHED BY rM1rN " F f��f 38 34', 6.r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Jane's Way Property Address i Roche Family Realty Trust Owner Owner's Name information is rY 11, 2011ill t Oserve MA 02655 January required for every page. Cityrrown State Zip Code Date of Inspection I 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 filling out A. General Information forms on the computer,use 1. Inspector: `i 1 only the tab key to move your Patrick M. O'Connell _ cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. I Company Name 189 Cammett Road _ Company Address Marstons Mills MA 02648 City/Town State Zip Code 508.428.1779 SI 12855 Telephone Number License Number j I B. Certification i fi I certify that I have personally inspected the sewage disposal system at this address and that the f 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 f Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails d may. ❑ Needs Further Evaluation by the Local Approving Authority / ••` cry January 11, 2011 Job# 11-04 In ector's Signature Date ' The system inspector shall submit a copy of this inspection report to the Approving Authority-(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 ownl 1, 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. lJ v t5ins•09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal ystem•Page i1 of 17 r I I Commonwealth of Massachusetts Title 5 Official Inspection Form f p t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 11 Jane's Way Property Address i Roche Family Realty Trust I Owner Owner's Name information is Osterville MA 02655 January 11, 2011 required for, rY every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) i Inspection Summary: Check A,B,C,D or E/always complete all of Section D • i I A) System Passes: j ® 1 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. I Comments: ff Tank had liquid only and is not in need of pumping at this time, leaching system is less than two I years old and shows no signs of surcharge. I _ I f — i B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be j 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. t 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. a ❑ Y ❑ N ❑ ND (Explain below): l 4 I 1 1 I f i - i i - t5ins-09/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 2 of 17 I i � 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 11 Jane's Way i Property Address Roche Family Realty Trust I Owner Owner's Name information is 11, 2011 required for Osterville MA 02655 JanuaryI _ every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) j B) System Conditionally Passes (cont.): }4 ElObservation 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. Systemwill pass inspection if(with approval of Board of Health): 1 ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below). i ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): I i i I i I I i, ❑ 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): El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 1 I I _ i i — j I 3 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 hed lt:h, safety and the environment: i ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 3 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form { Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i �M 11 Jane's Way Property Address Roche Family Realty Trust f Owner Owner's Name information is required for Osterville MA 02655 January 11, 2011 _ every page. Cityrrown State Zip Code Date of Inspection I B. Certification (cont.) i 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 wafter supply. I . - ❑ 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 4 more from a private water supply well**. Method used to determine distance: i — **This system passes if the well water analysis, performed at a DEP certified laboratory, for colifoirrn 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. ' i i 3. Other: i i — D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: ! I Yes No j Backup of sewage into facility or system component due to overloaded or j ❑ ® clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static Liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow _ t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page i4 of 17 f I� Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Jane's Way Property Address Roche Family Realty Trust Owner Owner's Name information is , required for Osterville MA 02655 January11 2011 � every page. Cityrrown State Zip Code Date of Inspection I B. Certification (cont.) i Yes No I ❑ ® Required pumping more than 4 times in the last year NOT due to clogged o` obstructed pipe(s). Number of times pumped: I ❑ ® 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,, I' 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. [,Ills 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. i I E) Large Systems: To be considered a large system the system must serve a facility with a 1 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. t 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 11 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. I t5ins•09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i M 11 Jane's Way Property Address Roche Family Realty Trust _ Owner Owner's Name information is , required for Osterville MA 02655 January11 2011 - every page. CityRbwn State Zip Code Date of Inspection C. Checklist a Check if the following have been done. You must indicate"yes" or"no" as to each of the following: I Yes No I i l ® ❑ Pumping information was provided by the owner, occupant, or Board of Health i I ❑ ® Were any of the system components pumped out in the previous two weeks? i ❑ ® Has the system received normal flows in the previous two week period? j ❑ ® 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? r r i ® ❑ Were all system components, excluding the SAS, located on site? i ® ❑ 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? a ® El information the facility owner(and occupants if different from owner) provided with j 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: j ® ❑ Existing information. For example, a plan at the Board of Health. I ® ❑ 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 i Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 i — f DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 i l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page B cf 17 i 1 i i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 Jane's Way j Property Address Roche Family Realty Trust Owner Owner's Name information is O required for sterville MA 02655 January 11, 2011 every page. Cityrrown State Zip Code Date of Inspection { D. System Information Description: I I I I -Number of current residents: 0 I — Does residence have a garbage grinder? ❑ Yes ®� No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ®1 No Laundry system inspected? ❑ Yes ❑I No Seasonal use? ❑ Yes ®i No Water meter readings, if available(last 2 years usage (gpd)): — E Detail: Sump pump? ❑ Yes ® No Last date of occupancy: April 2010 — Date Commercial/Industrial Flow Conditions: Type of Establishment: — II Design flow (based on 310 CMR 15.203): ` — Gallons per day(gpd) ,l Basis of design flow (seats/persons/sq.ft., etc.): — Grease trap present? ❑ Yes ❑f No Industrial waste holding tank present? ❑ Yes ❑l� No { Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑! No Water meter readings, if available: ! — i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 cf 17 I f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 11 Jane's Way Property Address j Roche Family Realty Trust Owner Owners Name information is required for Osterville MA 02655 January 11, 2011 every page. Cityrrown State Zip Code Date of Inspection i D. System Information (cont.) M Last date of occupancy/use: Date i Other(describe below): ` I j I General Information j i Pumping Records: I Source of information: None since new leaching system installed. i Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: — gallons I How was quantity pumped determined? t _ 1 i Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system i I ❑ Single cesspool ❑ Overflow cesspool . k ❑ Privy i I ❑ 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 . j ❑ Tight tank. Attach a copy of the DEP approval. I ❑ Other(describe): !Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i i . f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 11 Jane's Way Property Address Roche Family Realty Trust Owner Owner's Name information is Osterville MA 02655 January 11 2011 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Y Approximate age of all components, date installed (if known) and source of information: t Compliance date: 3/2/09 e t Were sewage odors detected when arriving at the site? ❑ Yes ® No• i i Building Sewer(locate on site plan): � 1' 1 Depth below grade: feet i Material of construction: i ❑ 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.): I i i i i Septic Tank(locate on site plan): 8" Depth below grade: feet Material of construction: l ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(exp►ain) I I I If tank is metal, list age: — years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ I o 8.5' long x 5.2'wide- 1000 gal Dimensions: — 0" Sludge depth: — t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i I i -Commonwealth of Massachusetts a _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 11 Jane's Way- Property Address Roche Family Realty Trust Owner Owner's Name information is Osterville MA 02655 January 11, 2011 required for ry every page. Cityrrown 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 ! — Scum thickness 0 11 Distance from top of scum to top of outlet tee or baffle I i Distance from bottom of scum to bottom of outlet tee or baffle Measured How were dimensions determined? — Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank had liquid only, no solids. Liquid level was found at bottom of outlet invert and tees were intact and clear. E i I' i - i j — i I Grease Trap (locate on site plan): i Depth below grade: feet Material of construction: f r ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): j — Dimensions: — Scum thickness I — Distance from top of scum to top of outlet tee or baffle - - i Distance from bottom of scum to bottom of outlet tee or baffle — Date of last pumping: Date — t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 o':17 { I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Jane's Way Property Address t Roche Family Realty Trust Owner Owner's Name information is Osterville MA 02655 January 11, 2011 required for rY every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.).- Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: — Capacity: — gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date i Comments (condition of alarm and float switches, etc.): I 1 I — i `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1:1 of 17 A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Jane's Way Property Address Roche Family Realty Trust Owner Owner's Name information is Ostervill January ,e MA 02655 Janua 11 2011 required for ' 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): 011 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.): No solids or high stains present. 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.): i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 11 Jane's Way Property Address Roche Family Realty Trust Owner Owners Name information is Osterville re uiredfor MA 02655 January 11, 2011 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type. ❑ leaching pits number: ® leaching chambers number: 6 Arc 50s. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system i Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Area surrounding SAS was probed with no signs of saturation found. SAS shows no signs of surcharge. f . i Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): t Number and configuration — i Depth—top of liquid to inlet invert = Depth of solids layer — Depth of scum layer — Dimensions of cesspool — Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 cf 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 11 Jane's Way Property Address Roche Family Realty Trust Owner Owner's Name information is required for Osterville MA 02655 January 11,2011 every page. Cityffown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetaticn, 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.): - x t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 Jane's Way Property Address Roche Famil ry Real Trust Owner Owner's Name _..... .........._.....--..... ---- - ------- - — ---- information is required for Osterville MA 02655 January 11, 2011 p State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, includingties 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 Jane's Way / I / / ! / ! ! / ✓ / l 1 / + f l I ! / J r J / / r J / / r / f i •r `/ '/ / 38 r4, 34 7 <` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 11 Jane's Way Property Address Roche Family Realty Trust Owner Owner's Name information is Osterville NIA 02655 Jana 11, 2011 required for -January every page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: 4 ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el.20 and topo map shows property at el. 50. Before filing this Inspection Report, please see Report Completeness Checklist on next pagla. t5ins-09/08 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 w 11 Jane's Way Property Address Roche Family Realty Trust Owner Owner's Name information is required for Osteryille MA 02655 January 11, 2011 every 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 l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 0l 17 y.. TOW F BARNSTABLE LOCATION "5' .z.�S SEWAGE#c20a`r pyC3 Vi LAGE o ASSESSOR'S MAP&PARCE . INSTALLER'S NAME&PHONE NO. D�tnS{�Qlt¢ SrnrE ��b - r,2©i. b SEPTIC TANK CAPACITY_ ((20 0 c,c,\ LEACHING FACILITY:(type) (p h„rr Sp'y (size)a f a 3 NO.OF BEDROOMS 3 1 OWNER ":�r^vM PERMIT DATE: Z e 2,6 Q 5 COMPLIANCE DATE: D Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility N P. feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) ,P,` feet. Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facili feet FURNISHED BY i 3 f3 IL �1 A C 1 ® e No.. v Fee_ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes vl ZIpprtcattou for �tgpogal 6pgtem Cougtrurtton Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. %� Tf�/l E'f WA" Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No.30vl Yie Q Designer's Name,Address and Tel.No. h/gC &DV V f30X 6 �5 SA�(�w�cGi �e o -5G3 ��57 � ill��viG 7 /114 Aep 20/e Z%7-2 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building r14 /� ,�/ ��/X, No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) -73 D 'd gpd Design flow provided ��O gpd Plan Date Z-�5 '4�J Number of sheets Revision Date NdA-1-C Title Size of Septic Tank 16b0 _XrS7r�✓�j Type of S.A.S. CGJ 9w, e-I 4�c- S?/ k 6 Description of Soil A_ - /11111 Nature of Repairs or Alterations(Answer when applicable) �i�tom_/ �/2 c� L'a �'✓1 7`Lj 41f-C D Cam,Ww�6.e�s c✓� �- Cl-­If(mod f7,^A 411-01­7 1 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 and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Date . Application Approve Date Application Disapproved by: Date for the following reasons Permit No. �0 L/d Date Issued No �Fe / Entered in computer: / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Migoal *p6tem Cou.5tructton Fermat Application for a Permit to Construct O Repair O Upgrade O Abandon O ❑ Complete System ❑IndividuahComponents 1 w, Location Address or Lot No. 3,4/1 ej' &a4.e_(r 4 I Owner's Name,Address,and Tel.No. S '/ �o Assessor's Map/Parcel Installer's Name,Address,and Tel.No. u,l f,P Id J�✓t ��/� �/�C C/V v / Designer's Name,Address and Tel.No. /3oX6 s/r1l� "rcl� N^q G25G" 4-F-iq.3 j �/-141.) v J-Dr 4?7 ? Type of Building: Dwelling No.of Bedroom Lot Size (V sq. ft. Garbage Grinder ( ) Other Type of Building ,�;���.GA/ iQ.r�/�r� No.of Persons Showers( ) Cafeteria( ) Other Fixtures .�. 1 1 Design Flow(min.required) +.� 3� '_UY ,gpi�, Design flow provided, � �'- J gpd Plan Date Z - `� "a C7 Number of�sheets k Revision Date Titled` t c Size of Septic Tankn ' 16b0, �,( f i�✓� {Type I e A.S. C'G� g 2 4� - f c S?/ X (o . Description of Soil U / rd � P! 1, Nature of Repairs,o Alterations(Answer when applicable) r to A-G1C v CGi A,01 ✓l,.-o 1 4 t 'Date'last inspected: l v Agreemebti The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in ae ordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of' Comptiance has been issued by this—Board of Health. Signed-, Date 2" 6 , 9 _ Application Approved(bx \ r Date �. `Application Disapproved by: M Date - � for the following reasons Permit No. Y -® O Date 11 Issued U ,> ———————. 61y THE COMMONWEALTH OF MASSACHUSETTS' ' BARNSTABLE, MASSACHUSETTS { i• Certificate of Cony Y.tance= - THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( �) Upgraded ( ) Abandoned( )by 3&-,5CIe /e/ fg>'/ if Y�y .l'c°�-L,., c__e aMC at �7'47.t _( �_.W4,j has been constructedin accordance y� with the provisions of Title 5 and the for Disposal System Construction Penn'ft'N dated 4- hd�- Installer i- f e r e�Desi ner I/�DuS.i /�( Rvi� G> g #bedrooms 3 + AppiovedZ?L%t�wi ' C gpd The issuance of is err;t sha not be construed as a guarantee that the system will as designed. Date ') Inspector /� t � , ———————— ———————————=————————————— .... ..^�———No. ` � 7.t/ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Mi.ponl:�P!5tem Construction Permit Permission is hereby granted to Construct ( ) Repair (X ) Upgrade ( ) Abandon ( ) System located at �/ ti%/��)PS CGVtw, „1.�_. OS7c'.-L// /�e and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditi/ojis Provided: Constructio must b completed within three years of the datelof this perm . Date / Q Approved b ' X Town of Barnstable P# . � Department of Regulatory Services f �� Public Health Division Date / 9 tb p. �s� 200 Main Street,Hyannis MA 02601 , 3 All Date Scheduled f� -Time Fee Pd. S it Suitability Assessment for Sewage Disposal L '7 Performed By: Witnessed By: � 1 LO.CATION & GENERAL-WO.I�1V]�ATION Location Address 'I �n I,/6 //�A � Owner's Name Address Assessor's Map/Parcel: %/�/ Q Engineer's Name NEW CONSTRUCTION REPAIR Telephone Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing-Water in Ho!e:—._ — -x — Weeping from Pit Face. Estimated Seasonal High Groundwater ` DETERMINATION FOR SEASONAL THIGH WATER TA L E Method Used: Depth Observed standing in obs.hole: In. Depth to Boil mottles: _ in. Depth to weeping from side of obs.hole: _ In. Groundwater Adjustment_ ft• Index Well# Reading Date: Index Well level, Adj.factors Adj,Groundwater Level I'L+R' l .ATOI TEST 4ate 'ltxia Observation f /Hole# Time at 9" ' Depth of Perc Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP OBSERVATION MOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. V0.7 Consistenc %Gravel DEgP OBSERVATION HOLE.LOG $ote# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel 1 DEEP OBSERVATION HOLE.LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA )) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel DEEP'OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, o Gravel) Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pe io erial exist in all areas observed throughout the area proposed for the soil absorption system? r ' If not,what is the depth of aturally occurring pervious material? Certification I certify that on Ib (date)I have passed the soil evaluator examination approved by the Department of Enviro ental Protection and that the above analysis was performed by me consistent with the require 1 aining,a erti a e perience described in 310 CMR 15.01 Signatur . Date 6 Q:\SEPTICIPERCFORM.DOC I � ' F WINNOW Town of Ba rjastable �. Regulatory Services Thomas F.Geiler,Director ftblic Health Division A Thomas McKean,Director 200 lain Street,Hyannis,MA 02601- Office:.508-862-4644 -fax: 509-790-634 Installer&Designer Certification Form /20C) Date: t , Designer: DI Y/1J c�' Y)N604 installer:.° 8�05FI Address: . E95/- Address: on C�'O? Og � G_ was issued a ermit to rinstall a (date) (installer) p septic system a t. l V*c�7 eased on a design drawn by (address)' dated designer) _Z pertify that-the septic`system referenced above was installed substantially according'to lie d=gn, which may include minor approved-changes such as latq&liefocatioji of the d t ibudon box and/or septic tank I cettif}+11hat the septic system referenced above was insta4pd vn ' r_chauges'(jre, greater t110' lateral relocation,of the SAS or any ve�tcallocion'of anycompo� of the-seP� ? but ui aeoordance with State&Deal Re-V lations. Plan revislo�or certittied as bit`by dew�gaer fo follow. t r � ,>EJI1 IW9AS.ON s9NlAR�p� er s Signature) - { sfanzp Flere) a PLEAgE I2E1'UItN TO $A ST —bBLI EWALTII MIN9IU OF COMICUNCE Wff T N UED� - OTHa- OFCMM _I&f CAR D A 1tEgg� B, . KT:ABLE P SI0N: OU. Q:Healweptic/Designer Certificiti QU,Form `. °i J ' COMMONWEALTH"OF MASSACHUSETTS z f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS p M d DEPARTMENT OF ENVIRONMENTAL PROTECTION e� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A --;4 CERTIFICATION Property Address: 23 Jane's Way,Osterville,MA =y Owner's Name: Carol Darelius Owner's Address: 11 Joyce Lane,Bellingham,MA 02019 c Date of Inspection : 06/11/2007 •• • -s ter .,• ` - Name of Inspector: Michael T.Bisienere Company Name:.A&K Septic Systems Plus Mailing Address: 565 Carriage Shop Road,East Falmouth,MA 02536 Telephone Number: 508-540-6706 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: X Passes Conditionally Passes Needs Further.Evaluation by the Local Approving Authority Fails Inspector's Signature: a e 06/11/2007 . 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. Notes and Comments:System functioning fine.There,is no evidence of failure criteria. System consists of 1000 gallon tank and 1000 gallon precast leaching pit. **.**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. r . Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:23 Jane's Way,Osterville,MA Owner: Carol Darelius Date of Inspection:06/11/2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: , X 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: Titles G.1--t;n Pn 2 Page 3 of 11 „ OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 23 Jane's Way,Osterville,MA Owner: Carol Darelius Date of Inspection:06/11/2007 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 2. System will fail unless the Board of Health and Public Water Su tier'if an determines that the Y ( PP � Y) , 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 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 i 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:23 Jane's Way,Osterville,MA Owner: Carol Darelius Date of Inspection: 06/11/2007 D. System Failure Criteria applicable to all systems: ' You must indicate"yes"or"no"to each of the following for all inspections: ` Yes No x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool x Discharge or ponding of effluent to the surface of the ground or surface.waters due to an overloaded or clogged SAS or cesspool x Static liquid level iri the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool x Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped x Any portion of the SAS,cesspool or privy is below high ground water.elevation. x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. x Any portion of a cesspool or privy is within a Zone i of a public well. x Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ x 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 CNM 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: t 1. 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. T41.G 1-...f;- r.— Ail r,i')nnn 4 Page 5 of I 1 ; OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:23 Jane's Way,Osterville,MA Owner: Carol Darelius Date of Inspection: 06/11/2007 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No x _ Pumping information was provided by the owner,occupant,or Board of Health: x Were any of the system components pumped out in the previous two weeks x _ Has the system received normal flows in the previous two week period? x Have large volumes of water been introduced to the system recently or as part of this inspection? x Were as built plans of the system obtained and examined?(If they were not available note as N/A) x Was the facility or dwelling inspected for signs of sewage back up? . x Was the site inspected for signs of break out? x Were all system components,excluding the SAS,located on site? x 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? x Was the facility owner(and occupants if different'from owner)provided with information on the proper maintenance of subsurface sewage disposal systems?. ' - t The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no x Existing information.For example,a plan at the Board of Health. x 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)] 1 5 Titles i lncnartinri Fnrm (+/1 V711M Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:23 Jane's Way,Osterville,MA Owner: Carol Darelius Date of Inspection:06/11/2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual):3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd z#of bedrooms): 330 Number of current residents:2 Does residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no):no [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)): 060637 Sump Pump(yes or no):no Last date of occupancy:current COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.); Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Owner Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped:,How was`quantity.pumped determined? Reason for pumping: ' TYPE OF SYSTEM .x Septic tank,distribution box,soil absorption system s 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: 1983,owner Were sewage odors detected when arriving at the site(yes or no):no Tula G 1-e ,t;n Rnrn, 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 Jane's Way,Osterville,MA Owner: Carol Darelius Date of Inspection: 06/11/2007 BUILDING SEWER(locate on site plan) Depth below grade: 6" Materials of construction:_cast iron _X_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 X (locate on site plan) Depth below grade: 12" Material of construction: x 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: standard 1000 gallon tank Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle:23" Scum thickness:2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle:20" How were dimensions determined: field instruments Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):Recommend pumping every two years. Structural integrity is fine.Liquid levels in relation to tees are fine and there is no evidence of leakage. - GREASE TRAP: NA(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.): i Titles S Tnenartinn Rnrm.(./1 G/7(lh(1 7 I 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: 23 Jane's Way,Osterville,MA Owner: Carol Darelius Date of Inspection: 06/11/2007 TIGHT or HOLDING TANK: NA (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,etc.): DISTRIBUTION.BOX: NA(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.): PUMP CHAMBER: NA(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title G 1--t;n r7--A/1 v,)nnn 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: 23 Jane's Way,Osterville,MA Owner: Carol Darelius Date of Inspection: 06/11/2007 SOIL ABSORPTION SYSTEM(SAS): x (locate an site plan,excavation not required) If SAS not located explain why: Type x leaching pits,number:l leaching chambers,number: y 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.): 1000 gallon precast leaching pit.No sign of hydraulic failure.Condition of soil and vegetation is fine.:Cover down 1'. CESSPOOLS:—NA (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: NA (locate on site plan), . Materials of construction: bimensions: Depth of solids: Comments(note condition of soil;signs of hydraulic failure,level of ponding,condition of vegetation,etc.): .'Titles T„—.,f;—17—A/1 G111W) 9 - - Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: : 23 Jane's WaY,Osterville MA Owner: Carol Darelius Date of Inspection:06/11/2007 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. J - 7 ' PTF - -27 / T41a S 1—...t;n R.,_A/1 r'ilnnn 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:23 Jane's Way,Osterville,MA Owner: Carol Darelius R Date of Inspection: 06/11/2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting'property/observation hole within 150 feet of SAS). Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation). Accessed USGS database-explain: . You must describe how you established the high groundwater elevation: Augured Hole @ 12 feet-No H2O ,n ASSESSORS III -- -PARCEL : TEST HO_E LOGS ` S , FLOOD ZONE : Ir q l� ���(,,�- SOIL EVALUATOI : w -- WITNESS : 1 The installation shall comply with Title V and Town of Barnstable Board of � � REFERENCE: ��� 1 .����.►�}�-- {'�2l✓Y���..� L Zob�_ 0 ) p Y �-..� � DATE: ��1�-IUD Health Regulations. �1ful c�"jgl PERCOLAT ION R4T : z i� tL�l, 1 , - -- ---------- --T --- —I �7 -- -- 2) The installer shall verify the location of utilities, sewer inverts and septic ( \N& _ components prior to installation and setting base elevations. TH- I TH-2 3) All gro-v;ty -,entir.ninino7 to hP a inch 'rh 40 PVC at 1/8"per fe^t. The first 64W t( 9 1 �' D two f--1 out oftl t.- d-box to the leaching shall be level. _ {2 _ � i✓ 4) This plan is not to be utilized for property line determination nor an other (o !o � Y `?�4 Lb'�'''`� �'' purpose other than the proposed system installation. mm ✓ -_-Tyr.; �D L 1 1 ,1� 5) All septic components must meet Title V specifications. �i6 "- - 6) Parking shall not be constructed over H10 septic components. LOCATION MAP ev, 7) The property is bounded by property corners and property lines. ' 'S'' '` 8) The property owner shall review design considerations to approve of total 4/1 (L1' 115 design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed / approval of the design flow by the owner. `�'` 9) The existing lcacamig or cesspools shall be pumped and filled withmateriai - - i r Title V abandonment procedures. Those within the ._ - �o t �;2, 1,J r?_-_ _-_ qO t,�-qD. 1,01;J f be removed along with contaminated soil and replaced with lean sand per ll Title V specs. — 10)System components to be 10 feet from waterline. Sewer lines crossing the ``. =� water line shill be sleeved with 4 inch SCH 40 PVC with ends routed if < f S E P T I C SYSTEM DESIGN applicable. The proposed SAS is being g �' 1 PP i " P I g installed below the water service FLOW ESTIMATE line. The line is to be sleeved as aforementioned and maintained in place. 11) If a garbage grinder exists it is to be removed and is the responsibility of the 3 owner to ensure such. BEDROOMS AT CIO GAL/DAY/BEDROOM GAL/DAY " 12)The installer is to take caution in excavation around the as line. g 13)The installer shall verify the location, quantity and elevation of the sewer SEPTIC TANK lines exiting the dwelling prior to the installation. f I GAL/DAY x 2 DAYS - GAL USE 100 GALLON SEPTIC TANK _� x�S-I"I�1.�; - �- SOIL ABSORPTION SYSTEM 14 s / I r.�wli`.,._ -VV2 tryP V_. a�,,l V'�UV Le - � � fad ,�. � � Z- SIDE AREA: Z-93(� �C`C, BOTTOM AREA: 7 L4 MA Z ? (o X ! p 1 = 4{ 9'N i SE T ' C SYSTEM SECTIONT`� — _' L_._----__ � _._ ------_ •' -- ----- z : � of C It aD Tf wd? 2 Of��8' n In t.lk. F;i MAX 1000 GAL 1, I� D J I a b o D 0 D 0 _ - SEPTIC TALK }3 ot� IT - 1 , t ��N 0FM,4 I a D B. CD Y G'G Na. S I TE AND SEWAGE PLAN '•£� OJT-�fZ V I I/L.-'� � F _ ----- -- - = PREPARED FOR : —nlll KI OF-VI/ t. SCALE: 117� z DAV I D B . MASON R� DATE: J .: - DBC ENVIRONMENYAL DESIGNS z A .- __—._ _ _______ _ EAST SANDWICH . MA DATE HEALTH AGENT ( j08 ) 833— 2177 s.�rr.s+.eusegrr .sar ,.,-�::cw�armaxm=...aE as+a.,...:sm .>.,�z�aa.x,...a.��:.�.,zap-ins:�+c�c:-.r*,,.rr-..:.u:n..-�rz:�s+e�:.sz::zc.aemcx'msaz a;,ic'.s:cvr,"...�mcuram�,w::cau.s;:=r- u.-.:--.�+.mxer..-n :s=zc__r�.dsm.�w.::z.vc-�rnv::...a•_.....- .�x::wr;:_za-a.:..:e.:-+a�e:.,u:<-*ec,as,..e..:a�.n`a.ssm.�.x.�i-..--nw.-:sr�r:..�w..v.:ersrecro=�.,+ma.x-swa ..:�xs.im-:a re. .-rvu:.-=�.�,c:.�