Loading...
HomeMy WebLinkAbout0014 JASON'S LANE - Health F 29 Hickory-Hill Circle tei vine l21 - 129 Y I l- REGISTRY OF DEEDS - BARNSTABLE COUNTY ,TTORNEY AT LAW UNREGISTERED LAND DEED 800K 21827, PAGE 326, PARCEL $ `S PLAN BOOK 211, PLAN 135 LOT(S) 16 C. STAPLES REGI�,TERED LAND „-- 19 2008 L.C. PLAN SHEET LOTS) > 121, BLOCK LOT D39 CER71FICA7E OF TITLE W MORTGAGE NSPECHON PLAN 40. #729 MlCKORY WU aRCLE, OSM?WLL& MA IN/F SCUDDER �. ..� PLAN BOOK 271, PAGE 135 �Ao [o Z(pf) IVIF AMES y 15,545.E SQ. FT. i LOT 15 9 }} o� / 1 / LOT T 17 P4RC� Arr_ LO T 1 TO IVE A=149.61 p LA. � R=313.20' { MCKORY MU CR?CLE THIS PLAIN IS FOR MORTGAGE PURPOSES ONLY SHEET 1 OF 2 1 i CER1tf7CA770/V I COMFY THAT THIS PLAN.WAS PREPARED IN ACCORDANCE W7H THE '• - PROCE'WRAL AND TEaINICAt, STANDARDS FOR THE PRACTICE OF i HEREBY CERTIFY TO THE BEST OF MY KNOWLEDGE LAND SURWMG IN 7HE C10IMONNE40H OF MASSACHUSETJS 250 AND BEUEF TO TW ABOW ATTORNEY, BANK AND CUR SEC71 N 6.05 ARID W7h` THE REMARKS SHEET ATTACHED NFRE'TO AND THEIR 7171.E INSURANCE COMPANY, THAT THERE ARE NO 09BLE ENCROACHMENTS OR EASEMENTS EXCEPT AS SHOWN, AND THAT THIS PLAN WAS PREPARED UNDER MY ImmEDIATF SUPERWSION. OF iom CONSULTING LAND SURVEYORS 97 COME STREET, .NEW BEDFORD, MA 02744 Fri a JEEL: (cos) sss-Dios FAx(5os) sss-2sso sf John.��rbbycans,lt ting,com � i www.jibbyconsu,lting.com 1 I r 4UmTP R ag, 141 Cet)-* 1 - E t JAR ks T FLU lop, 7.0 � 1 x �y e i } r Pole CL- LL e WED 84TH qUD IT14- �r s OICKORY HILL C1RCL , 1 '. &E OS � o � S CCU R T :ECT c , s - y �i . 3 s lo g r ( TkE T f, 1 i t KG;Rid° HILL Clkccc , L E V E1� `) 5- TERN' i t.: off RZE s j� = /CSC paih+ d wail'�� (oteweir Viet too r o r3'1P P6 free r1 Ov . in l F 9 {P3 v tA L � W LP li - cnA MEA 9-a�IpV AlllU I`� T7 C ireOQ �- 77- tz--c "I.c u yie cil� r WALL HEAJcy V d©ar Q+f6p ' y� 3 1 i - T , a j e- Yam'sulafe. a TA A, LAI Of COmPu7'ER.-PO,O Y1 f► ' ��. do UNF1 N t-SH : TRH GAS Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �s GSM 12.9 Hickory Hill Circle Property Address P9"� Judy Staples Owner Owner's Name information is required for every Osterville Ma 02655 12/28/17 � page. Cityrrown State Zip Code. Date of Inspection CO yt+: 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 forms A. General Information s� / on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain r� Company Name 35 Content Ln Company Address Cotuit MA 02635 City/Town State Zip Code 508-364-9587 S113522 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 Lo -Approving Authority 12/28/17 Inspector'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 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 oofCf 17 / Y V Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 129 Hickory Hill Circle Property Address Judy Staples Owner Owners Name information is Osterville required for every Ma 02655 12/28/17 page. Cltyrrown 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: System contains a 1,000 gallon leach pit currently acting as the septic tank followed by another leach pit that is working as designed. Staining is only 1 ft up from bottom with 6" of water standing. 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal •System Page 2 of 17 Y 9 �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Hickory Hill Circle Property Address Judy Staples � P Owner Owner's Name information is required for every Osterville Ma 02655 12/28/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 l5ins•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 129 Hickory Hill Circle Property Address Judy Staples Owner Owner's Name information is required for every Osterville Ma 02655 12/28/17 page. City/Town 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 � Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Hickory Hill Circle Property Address Judy Staples Owner Owner's Name information is every serve a re Otill M 02655 12/2 /1 7 required for eve 8 q page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Zi Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ z Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z 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. ❑ z 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 El El the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone Il of a public water supply.well If you have answered yes"to any question in Section E the system is considered a significant threat, Q 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. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments H ,a' 129 Hickory Hill Circle Property Address Judy Staples Owner Owner's Name information is required for every Osterville Ma 02655 12/28/17 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins- /13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 r �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Hickory Hill Circle Property Address Judy Staples Owner Owner's Name information is required for every Osterville Ma 02655 12/28/17 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 178 Gpd 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date 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? ❑ 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: !Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Hickory Hill Circle Property Address Judy Staples Owner Owner's Name information is required for every Osterville Ma 02655 12/28/17 page. Cityfrown 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: Annually 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): Two Leach pits in series t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 �. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 129 Hickory Hill Circle Property Address Judy Staples Owner Owner's Name information is required for every Osterville Ma 02655 12/28/17 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: Original to home Were sewage odors detected when arriving at the site? ❑ Yes ® No BuildingSewer locate on site plan): ( P ) Depth below grade: 1 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.): Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1,000 Gallon pit If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 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 •"t 129 Hickory Hill Circle Property Address Judy Staples Owner Owner's Name information is required for every Osterville Ma 02655 12/28/17 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle " Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tee's are in place 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 wM 129 Hickory Hill Circle Property Address Judy Staples Owner Owner's Name information is required for every Osterville Ma 02655 12/28/17 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): 9 9 ( P P P ) ( P ) 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 H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Hickory Hill Circle Property Address Judy Staples Owner Owners Name information is required for every Osterville Ma 02655 12/28/17 page. Citylrown 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 NA 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(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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 129 Hickory Hill Circle Property Address Judy Staples Owner Owner's Name information is required for every Osterville Ma 02655 12/28/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ Reaching chambers number: ❑ Reaching 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.): System is working as designed 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Hickory Hill Circle Property Address Judy Staples Owner Owners Name information is required for every Osterville Ma 02655 12/28/17 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.): l5ins•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 ,M 129 Hickory Hill Circle Property Address Judy Staples Owner Owner's Name information is required for every Osterville Ma 02655 12/28/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks.or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °r 129 Hickory Hill Circle Property Address Judy Staples Owner Owners Name information is required for every Osterville Ma 02655 12/28/17 page. Citylrown 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: 15+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps indicate NGW at 15' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 D. System 1pformation (cons.) i Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal to at least two permanent reference landmarks or benchmarks. Locate all wells Locate where public water supply enters the building. � ' 1 100, i ' x1-1 15 i I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 129 Hickory Hill Circle Property Address Judy Staples Owner Owner's Name information is required for every Osterville Ma 02655 12/28/17 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 THE Town of Barnstable�F ip�,_ p� Regulatory Services. snxivsrnste Thomas F. Geiler, Director C7� MASS. . . 9w i 39. •�� Public Health Division � l Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 March 16, 2007 Ms. Joyce Miles 129 Hickory Hill Circle Osterville, MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system owned by you located at 129 Hickory Hill Circle, Osterville,MA was last inspected February 281h, 2007 by Robert Paolini, a certified septic inspector for the State of Massachusetts. The inspection of your septic system after further evaluation"Conditionally Passes". under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to.the following: Line from main leaching pit to overflow pit is orangeberg pipe with no tee in place. Line needs to be replaced with sanitary tee installed to prevent solids carryover. Inlet and outlet tees.need to be installed. Leaching pits appear to be structurally sound. No Distribution box present. Pump system every 2-3 years. You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH DEPARTMENT Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health `..._ 7 �{ --- Fee-'L — No '1 THE:COMMONWEALTH OF MASSACHUSETTS ' PUBLIC HEALTH DIVISION BARNSTABI E; MASSACHUSETTS '' �I� O$° � pgtQtYY �C�OYtztrtiLtOYCCrtYYtt ,j � '` Abandon Permission 1s'%ereby granted to Construct ,( ) Repair ( ) Upgrade ( ) ( ) - System.locat�eJd at 1 2c ! ' �� I}. Co-iccl e _. 05 rr," tic, r and as described In';the above Application for Disposal System,Constraction P,eimit.The applicant recognizes his/her duty to comply with Title`5 and the following local provisions of.special condition's. Provided: ons 'ction must be completed within three years of the date of this i t D,'ate Approved by`, l r j Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 129 Hickory Hill Circle Property Address Joyce Miles Owner Owner's Name information is required for Osteryille Ma. 02655 02/28/2007 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector:' only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name r� P.O.Box 763 Company Address t'' Centerville Ma. '02632 w3 City/Town State Zip Code . (508)428-4028 Telephone Number License Number jI B. Certification c,3 rn I certify that I have personally inspected the sewage disposal system at this address a d that the information reported below is true, accurate and complete as of the time of the inspecti n. 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 Z . Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 02/28/2007 Inspector'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 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. 129 hickory hill cir.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 . r Commonwealth of,Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 129 Hickory Hill Circle Property Address Joyce Miles Owner Owner's Name information is required for Osterville Ma. 02655 02/28/2007. every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 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: Line from main leaching pit to overflow pit is orangeberg pipe with no tee in place.Line needs to be replaced with sanitary tee installed to prevent solids carryover. ❑ 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 129 hickory hill cir.•08/06 ; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments h �M 129 Hickory Hill Circle Property Address Joyce Miles Owner Owner's Name information is required for Osterville Ma. 02655 02/28/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: No distribution box present. ❑ 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: 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 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. 129 hickory hill cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage-Disposal System Form -Not for Voluntary Assessments �M 129 Hickory Hill Circle Property Address Joyce Miles Owner Owner's Name information is OSteryllle Ma. 02655 02/28/2007 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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 ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 129 hickory hill cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M s. 129 Hickory Hill Circle Property Address Joyce Miles Owner Owner's Name information is required for Osterville Ma. 02655 02/28/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) \ D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El ® 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.] ❑ Z 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. 129 hickory hill cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M a' 129 Hickory Hill Circle Property Address Joyce Miles Owner Owner's Name information is required for Osterville Ma. 02655 02/28/2007 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® 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. ® El 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)] 129 hickory hill cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 129 Hickory Hill Circle Property Address Joyce Miles Owner Owner's Name information is required for Osterville Ma. 02655 02/28/2007 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 03 Number of bedrooms (actual): 03 .DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 01 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2005:11,000 g ( y g (gpd)): 2006:7,000 Sump pump? ❑ Yes '® No Last date of occupancy: unknown Date 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? ❑ 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: Last date of occupancy/use: Date Other(describe): 129 hickory hill cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 129 Hickory Hill Circle Property Address Joyce Miles Owner Owner's Name information is required for Osterville Ma. 02655 02/28/2007 every page. City/Town State Zip Code Date of Inspection. D. System Information (cont.) General Information Pumping Records: Source of information: 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) ❑ Tight tank. Attach a copy of the DEP approval. ® Other(describe): 2-1000 gallon leaching pits. Approximate age of all components, date installed (if known) and source of,information: 1971 Were sewage odors detected when arriving at the site? ❑ Yes ® No 129 hickory hill cir.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Hiokory Hill Circle Property Address Joyce Miles Owner Owner's Name information is required for Osterville Ma. 02655 02/28/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 20'+- feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑,polyethylene ❑ other(explain) Septic tank not present. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------------------------------------------- Dimensions: Sludge depth: Distance'from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? 129 hickory hill cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 129 Hickory Hill Circle Property Address Joyce Miles Owner Owner's Name information is required for Osterville Ma. 02655 02/28/2007 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.): Pump system every 2-3 years.lnlet and outlet tees need to be installed.Leaching pits appear to be structurally sound. 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 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): 1129 hickory hill cir. 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 129 Hickory Hill Circle Property Address Joyce Miles Owner Owner's Name information is Osterville Ma. 02655 02/28/2007 required for State Zip Code Date of Inspection every page. City/Town � p p D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): % Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 129 hickory hill cir.•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 129 Hickory Hill Circle Property Address Joyce Miles _ Owner Owner's Name information is required for Osterville Ma. 02655 02/28/2007 every page. City/Town State Zip Code Date of Inspection i D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ 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.): 7 129 hickory hill cir.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 129 Hickory Hill Circle Property Address Joyce Miles Owner Owner's Name information is required for Osterville Ma. 02655 02/28/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2-1000 gallon leaching pits Depth—top of liquid to inlet invert Depth of solids layer 0 Depth of scum layer 0 Dimensions of cesspool Materials of construction concrete precast Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Sandy soil.No evidence of hydraulic failure.Vegetation appears normal.Septic system was dry at time of inspection. Privy(locate on site plan): Materials of construction: l Dimensions Depth of solids Comments (note condition of soil,signs.of.hydraulic failure, level of ponding, condition of vegetation, etc.): 129 hickory hill cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments, c . °M 129 Hickory Hill Circle Property Address Joyce Miles Owner Owner's Name information is required for Osterville Ma. 02655 02/28/2007 every page. City/Town .State Zip Code Date of Inspection D. System Information (cont.) 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. l000 t. I ix � 129 hickory hill cir.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 129 Hickory Hill Circle Property Address Joyce Miles Owner 'Owner's Name information is required for Osterville Ma. 02655 02/28/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: 30' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used:Gaherty& Miller model 12/16/94 ground water elevations.Used:USGS observation well data June 1992.Used: Technical bulletin 92-000-01 plate#2 annual ranges of ground water elevations. 129 hickory hill cir.-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15_ No. / V � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipprication for ais;po!5a1 6poemc (fowaruction Permit Application for a Permit to Construct O Repair A Upgrade O Abandon O ❑ Complete System ❑Individual Components Location Address or Lot No. ('Z j A c6, Zy Alf Owner's Name,Address,and Tel.No. 36 j ee M"IC-S oS"�cetlj;IIP ; ✓164 1 ZS 1tr'�4oy, Fti)I Assessor's Map/Parcel 2l O _ -3 i 3 t STD%�i IIc 04 9 Installer's Name,Address,and Tel.No. °�,f���' ��� 'yes 1-"'" � Designer's Name,Address and Tel.No. P 0 -7o C_-,tcf.�a.t ANA Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building k 4xr I No.of Persons % Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) -3© gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title f1e.,p ;t. Ali 1-2 W k Size of Septic Tank Type of S.A.S. 6Q F fto_J Q` r Description of Soil Nature of Repairs or Alterations(Answer when applicable) 5-t1A! 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. Signed Date 3— ) -20<)'? Application Approved by Date d Application Disapproved by: Date (31 for the following reasons Permit No. Date Issued . t A ._..... .-. r.. ...w,w.r+�rtd_•""t.•-.r..v1-.r'`.r.,,,,�.y-a�_ --J..•..1.?-... -a1^:.•� ,y `. No. . / V Fee �OO THE COMMONWEALTHOF MASSACHUSETTS Entered in computer: PUBLIC`HEALTH DIVISION - TOWN O� BARNSTABLE, MASSACHUSETTS 3pprication for Di ogal *potent Cons;trurtion permit k 4 Application for a Permit to Construct( ) Repair,) UpgradeO Abandon( ) ❑Complete System ❑Individual Components 4 Location Address or Lot No. I 5 A'c 4o Z 7 14;-I f Owner's Name,Address,and Tel.No., S Cy C<'_ M',1 e5 bgr<�.v,11� � ✓►�evq ^ /L7 /.fiGo/1-�, l+�)1 f.i2�IP Assessor'sMap/Parcel 12j 03q �7�;�yLy 3y 3� _ �STCf�,ltr ry.q C�� &titer �,�e} _ Installer's Name,Address,ao 1.No. ) P� Designer's Name,Address and Tel.No. U 90-,< -7(-3 Type of Building: Dwelling No.of Bedrooms. 3 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building rj,-�,}< tiC.zn�\v No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3O gpd Design flow provided gpd Plan Date Number of sheets ! Revision Date Title NpA.-t A.i 4'iy Size of Septic Tank C,-e55 Oao\, Type of S.A.S. A -r�yu J Q Y,Description of Soil ` Nature of Repairs or Alterations(Answer when applicable) 1 v,ti 1 L4 S,so,1-y—, T(C A4-d `'L#71A.,v Date last inspected: Agreement: The undersigned agrees to ensure the construction and mlintenance_„pf 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. Signed. Date Application Approved by kk�,, _ / ,l' Date f S��� - Application Disapproved by: v v Date , Z for the following reasons Permit No. Date Issued ----------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired 6e_ Upgraded ( ) Abandoned 1: )by \ C-A R-e d S- at 2 ct 4;c1,0k. 1 tt CI CC1. has been constructed in accordance h with the provisions of Title 5 and the for Disposal System Construction Permit No. cpo Jq dated Installer 60cf-" ex 4-4pe1'�! 3 LLC,. Designer #bedrooms 3 Approved design flow gpd The issuance of this permit shall not be/construed as a guarantee that the system will function as de'sig ed. Date / Inspector ——— ———————————————————————— Z45No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Nuiopoal *pgtem Congtruction permit l Permission is hereby granted to Construct ( ) Repair (>) Upgrade ( ) Abandon ( ) 'i System located at 12 r 411r11.2, C,,/Z C1 e OS Ce'l" 1 I C i and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Const ction must be completed within three years of the date of this permit/ Date, Approved by f ' V