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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments,
;M Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
A. General Information
Important:
When filling out 1. Property Information:
forms on the a 5 v /
computer, use 4 JOBYS ft Lr\ OSTERVILLE,MA 02655
only the tab key Property Address
to move your SCOTT EFRON
cursor-do not Owner's Name
use the return
key. 6075 VIA CRYSTALLE
Owner's Address
r� DELRAY BEACH FL 33484
City/Town State Zip Code
9-10-07
Date of Inspection: Date
2. Inspector:
JASON BURNIE
Name of Inspector
D J BURNIE & SONS bluewater holding corp
Company Name
105 FERNDOC ST UNIT A i
r-,
Company Address
HYANNIS MA —d2601
Cityrrown State ':'Zip Code
508-775-0139 �`' cJ
Telephone Number
B. Certification
c� r"—
I certify that I have personally inspected the sewage disposal system at this address and thafthe r9
information reported below is true, accurate and complete as of the time of the insp ction. 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: OFrAgUi��i�
® Passes ❑ Conditionally Passes
JASON •'•yN'
❑ Needs Further Evaluation by the Local Approving Authority =Z. P.
• �:, BURNIE
9-10-07
Inspector's Sig Date �i):�FRTIF\�
The system inspector shall submit a copy of this inspection report to the A�f{x�jyS ��P�y(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a ed 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.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage D°isposal.System Form
' M
j
B. Certification (cont.)'
4 JOBYS RD OSTERVILLE,MA 02655
Property Address
OSTERVI LLE MA 02655
City/Town State Zip Code
SCOTT EFRON 9-10-07
Owner's Name Date of Inspection
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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.
Comments:
B) System Conditionally Passes:
rY
❑ 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.
0 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
ND Explain:
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System form .
' M I
B. Certification (cont.)
4 JOBYS RD OSTERVILLE,MA 02655
Property Address
OSTERVILLE MA 02655
City/Town State Zip Code
SCOTT EFRON t 9-10-07
Owner's Name Date of Inspection:
t
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 ins (with approval of Board of Health):
inspection if pp
❑ broken pipes)are replaced
i
❑ 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 pipes) 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
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Commonwealth of Massachusetts -
W` Title 5 Official Inspection Form
Not for Voluntary Assessments
,M y Subsurface Sewage Disposal System Form
B. Certification (cont.)
4 JOBYS RD OSTERVILLE,MA `02655 ._
Property Address
OSTERVILLE MA 02655
City/Town State Zip Code
SCOTT EFRON f 9-10-07
Owner's Name Date of Inspection '
C) Further Evaluation is Required by the Board of Health (cont.):
T r
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:
0 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 us'ed'to determine distance:
**This system passes if the well water_analysis,performed at a DER 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.
i
3. Other-
back Disposal System
Subsurface Sewa y
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Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Not for Voluntary Assessments
^M y Subsurface Sewage Disposal System Form
B. Certification (coat.) .
4 JOBYS RD OSTERVILL€,MA 02655
Property Address. '
OSTERVILLE MA 02655
Cityrrown State ZipCode
SCOTT EFRON 9-10-07
Owner's Name Date of Inspection
i
D)System Failure Criteria Applicable to All Systems:
You must indicate`"Yes" or"No"to each of the following foe all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
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
El ® Liquid depth in cesspool is less than 6° below invert or available volume is less
than 1/2 day flow
El ® 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 groundwater elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a.private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DER certified
laboratory,for fecal coliform bacteria indicates absent and the presence .
of ammonia nitrogen and nitrate nitrogen is equal to or Tess than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
of 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.
Yes 'No
The system fails. I have determined that one or more of the above failure
® criteria exist as described in 310 CMR 15.303,..therefore the system fails. The
System owner should contact the Board of Health to determine what will be
necessary to correct the failure.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
G N v>y`e
B. Certification (cont.)
4 JOBYS RD OSTERVILLE,MA 02655
Property Address
OSTERVILLE MA 02655
City/Town State Zip Code
SCOTT EFRON 9-10-07
Owner's Name Date of Inspection
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
i
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
13 El 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, .
i
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.
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Commonwealth of Massachusetts
Title 5 Official ,I nspection Form:
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M r
C. Checklist
4 JOBYS RD OSTERVILLE,MA- A2655
Property Address
OSTERVILLE IMA ` ' 02655
City/Town - State Zip Code•.
SCOTT EFRON i 9-10-07
Owner's Name Date of Inspection
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
t
YES NO
Z ❑ 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
❑ Z' 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 component- 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 inEthe field (if any of the failure criteria related to Part C is at issue
❑ ` ® approximation of distance is unacceptable) [310 CMR,15.302(5)]
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information
4 JOBYS RD.• OSTERVILLE,MA 02655
Property Address
OSTERVILLE: MA 02655
City/Town State Zip Code
SCOTT EFRON 9-10-07
Owner's Name Date of Inspection
Residential Flow Conditions:
unknown 3
Number of bedrooms (design): a Number of bedrooms (actual):
DESIGN flow based on310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
unknown
0
Number of current residents:
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
06=19 gpd
Water meter readings, if available(last 2:years usage(gpd)): 07=19 gpd
Sump pump? ❑ Yes ® No
unknown.
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 readingsjf available:
Last date of occupancy/use: Date
Other(describe):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M yvay`'
D. System Information (cont.)
4 JOBYS RD OSTERVILLE,MA 02655
Property Address
OSTERVILLE MA 02655
City/Town State Zip Code
SCOTT EFRON 9-10-07
Owner's Name Date of Inspection
General Information
Pumping Records:
CUSTOMER= SYSTEM PUMPED APPX 3 YEARS
Source of information: AGO
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
El 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:
BARNSTABLE BOH AS BUILT CARD 1986
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
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a.
Commonwealth of Massachusetts
Title 5 Official Inspection Form '
Not for Voluntary Assessments
Subsurface Sewage Disposal.System Form
D. System Information (cont.)
4 JOBYS RD OSTERVILLE,MA 02655
p :
Property Address F
OSTERVILLE MA 02655
City/Town State Zip Code
SCOTT EFRON- 9-10-07
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
22"
Depth below grade: j feet
Material of construction':
f
❑ 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):
1611
Depth below grade: feet
Material of construction:
® concrete 10 metal ❑ fiberglass'.' ❑ polyethylene ❑ other(explain)
If tank is metal, list age': . years
Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ . No
certificate)
--- ---- = ------------------------------------- ------------
1000
Dimensions:
411
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
2°
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
SLUDGE JUDGE
How were dimensions'determined? '
•
ubsurface Sewage Disposal System
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Page 10 of 16
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j
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
4 JOBYS RD OSTERVILLE,MA 02655
Property Address
OSTERVILLE MA 02655
C4,rrown State Zip Code
SCOTT EFRON 9-10-07
Owner's Name Date of Inspection
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,.etc.):
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
i
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):
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I
assachusetts
Commonwealth of M
Title $ Official Inspection Form
a Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
GSM
SV B
D. System Information (cont.)
4 JOBYS RD OSTERVILLE,MA 02655
Property Address
OSTERVILLE MA 02655
City/Town I State Zip Code
SCOTT EFRON 9-10-07
Owner's Name Date of Inspection
Tight or Holding Tank(cont.)
Dimensions:
Capacity: gallons
Design Flow: . gallons per day
! ❑
Alarm present: � ❑ Yes No
j -
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):
offDepth 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.):
THE BOX WAS FOUND WITH NO SOLIDS CARRYOVER AND IN GOOD CONDITION
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms In working order:
Yes
No
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Commonwealth of Massachusetts
u Title 5 Official Inspection Form. -
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
{
D. System Information (cont.)
4 JOBYS RD OSTERVILLE,MA 02655
Property Address'
OSTERVILLE MA 02655
City/Town State Zip Code.
SCOTT EFRON t 9-10-07 .
Owner's Name Date of Inspection
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:
} 1 6 X 6 WITH
® leaching pits number: STONE
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
El leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil; signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
THE PIT WAS FOUND WITH NO STANDING WATER IN IT
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assachusetts
Commonwealth of M
Title 5 Official Inspection Form
° Not for Voluntary Assessments ,
Subsurface Sewage Disposal System Form
G„M
5•y`•
D. System Information (cont.)
4 JOBYS RD OSTERVILLE,MA 02655
Property Address-
OSTERVILLE MA 02655
City/Town State Zip Code
SCOTT EFRON 9-10-07.
Owner's Name Date of Inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site,plan):
t
Number and configuration
t
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
t
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
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.):
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Commonwealth of Massachusetts
w . Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
4 JOBYS RD OSTERVILLE,MA 02655
Property Address .
OSTERVILLE MA 02655
City/Town State Zip Code
SCOTT EFRON 9-10-07
Owner's Name Date of Inspection
I
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 build 3 ing.
t
a C
D
A l
36 Q r
37
F 56
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Commonwealth of Massachusetts
Title 5 Official Inspection form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont:)
4 JOBYS RD OSTERVILLE,MA 02655,
Property Address
OSTERVILLE MA' .02655
City/Town State Zip Code,
SCOTT EFRON 9-10-07
Owner's Name Date of Inspection
Site Exam: j
Slope 410
Surface water /✓a,
J
Check cellar �/e f
Shallow wells �U
Estimated depth to ground water: 16 _?e e4�r�S/C. �e '-kx �►,o/�3 Q , ��'
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:
BARNSTABLE GROUNWATER MAPS DATED 2004
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
SDW-252 ZONE C 3-4 WATER LEVEL 47.4 3.0 X 12=T ADJUSTMENT
You must describe how you established the high ground water elevation:
a
FROM GRADE TO BOTTOM OF SAS IT IS 8'..IF YOU ADD A 4' SEPERATION+THE
ADJUSTMENT OF T YOU HAVE A TOTAL OF ,16. I USED THE BARNSTABLE WATER MAPS
DATED 2004 AND FOUND THE ELEVATION AT PROPERTY IS 30.5. THERE IS A POND AT
OLDHAM RD MAP 144 PARCELL 032.THAT IS AT ELEVATION 14 YOU HAVE A DIFFERENCE
OF 16.5'.YOU ARE OUT OF GROUNDWATER BY AT LEAST 1'.
EFRON T-5.doc.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
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Town of Barnstable
114E tp�
yPti� Regulatory Services
BARNSTABM ; Thomas F. Geiler,Director
MASS.
9� 16.59. .•� Public Health Division
AiFp��a
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report;this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
}
1�xfj,.4 q TOWN OF BARNSTABLE
LOCATION � Foh�L s` L--/1, SEWAGE
VILLAGE V �L �/�
ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NOC� CO.
SEPTIC TANK CAPACITY
a
LEACHING FACILITY:(type) /� (size) o"�'� r✓
NO. OF BEDROOMS �PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNEE Ail'
DATE PERMIT ISSUED: f "�
DATE . COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
�����
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THE COMMONWEALTH OF MASSACHusETTs
BOARD OF HEALTH
7r. ...........OF................ ...................
Appliration for Disposal Works Tantitrurtion Permit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
Location-Address or Lot No.
................................. ......................................................................................
er ddress
Robert Our Co., Inc1c_ Great Western Road North Harwich
............................................................................................... ..................................................................................................
Installer Address
Type of Building Size Lot....1.9aM5.0..Sq. feet
Dwelling—No. of Bedrooms............... 5..........................Expansion Attic Garbage Grinder ( )
04 Other—Type of Building ............................ No. of,persons............................ Showers Cafeteria ( )
04 Other fixtures ......................................................................................................................................................
Design Flow...............llc?...................gallons per person per day
. Total daily flow..........._. .............gallons.
Septic Tank—Liquid*capacity.!C?P!Ptgallons Length...'6..!�? Width:.'.*...'.1J0.'.'Diameter.............. Depth..�5.144.1.1
Disposal Trench—No.._.............: Width.....I.............. Total Length....................Total leaching area....................sq. ft.
z2t"�A e7 Length.................. �&'
Seepage Pit No.. .......... Diameter....IjP�........ Depth below inlet.......&.... Total leaching area..Z...1Gq. ft.
Z Other Distribution box (>e) Dosin t 4 4
0-4 Percolation Test Results Performed by....FPX.V.. .... j��4i ...... Date........7�.Z.2CS.(42.....
Test Pit No. I...GZ-...minutes per inch Depth of Test Pit........( ... Depth to ground water.'../J./A*......
Lip Test Pit No. 2................minutes per inch Depth of Test Pit..............._.._. Depth to ground water........................
.................4................ ................
. .... .........................................................
0 Description of Soil....L......rr.�.'F..... ....... .........................................................................
W I Z ......��at.—_t,,, *- ..............................................................................
...............
.................................................................................................... .............................................w................V..................................
U Nature of Repairs or Alterations—Answer when applicable..............................................................................................
..................:.....................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of MI I: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Complianc ha been issued of health.
_A�
Sign ha
-Z, .1.... .................... ...............................
DatyApplication Approved By..... .......L.................................................................. ......
Date
Application Disapproved for the folla' g reasons:...........................................................................................................
......................................................................................................................................................................................................
Date
o................... ...... .Permit N ..................................... Issued................ ................................
Daft
Y7
No. rA el
................... Fics..........L ...
r.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
777n,1-4te4...... ....OF................ (J— 7
........................
Appliration for Disposal Works Tonstrurtion Permit
Application is hereby made for a Permit to Construct (K) or Repair an Individual Sewage Disposal
NA System at:
.....................................................
!:: Location Address
Address or Lot No.
. 4
_.j(
.................. ............................................................................................
Owner ddress
Robert Our Co., Inc. Great Western Road North Harwich
.................�6.................................................... ..................................................................................................
. Installer Address
Type of Building Size Lot....!.�Hl�.Sq. feet
Dwelling—No. of Bedrooms...............a........................Expansion Attic Garbage Grinder
04 04 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
04 'e
Other fixtures ........................................
< ..............................I.................................................................................
Design Flow..............1.1r......................gallons per person per day. Total daily flow_._..... 275:3«.............gallons.
Septic Tank—Liquid capacityR?�gallons Length....RYR!.'.'. Width_An..1.0.1. Diameter:-_----'...... Depth..F.:;.'4.'.
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No. e.':? Diameter....I .......Depth below inlet.......e'4:1....... Total leaching area..Z esq. ft.
z Other Distribution box Dosing tank.
Percolation Test Results Performed by._ ! !` ....... ...... Date._. __. .......
Test Pit No. I...j5;;_&..minutes per inch Depth of Test Pit........ Depth to ground water.... .......
44 Test Pit No. 2................minutes-per inch - Depth of Test Pit.................... Depth to ground water._._........_.._...._...
P4 ......................................................................
...................................................................w.................
0 Description of Soil.... ........*....... .........................................:......
..............................................
...................................................................
....................
.....................................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when.applicable................................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLITLZ' 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance hasbeen issued by thetboard of health.
•
Signed.'_./n;:n.................................... ................................
v ......................DatApplication Approved B ..... 12-- )0-Fj1=1y ........... .......... ...........................
Date
Application Disapproved for the follbwing reasons:..........................................................................................................
......................................................................................................................................................................................................
Date
PermitNo......... .................... ISSUC&......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............T........OWN .......:........OF.... .....BARNSTABLE
................................................................
Trrfifiratp of Tompliana
THIS IS TO CERTIFY That the Individual Sewge Disposal System constructed (X or Repaired
by...........Kobert..OurCo.. Inc.
.,.... .., ... Great..Western....oad.,...N.. .e...Harwich..........................................................
............. .............. .............................. ........ ... ..............
Lot 18 Joby's Lane Ostery lle Installer
......................................................................................................................................................................................................
at i
has been installed in accordance with the provisions of %TLE 5 of The State Sanitary Code as described in the
.................application for Disposal Works Construction Permit No./;, ............... dated._.Jl ..!.!
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.... I........... .... Inspector.... ....................................................................
... . ..
..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOM OF. BARNSTABLE
No......................... ........................................... ........................... ................
Disposal Works Tonstrurtiott Permit
Permission is hereby granted..............Robe.rt...0ur..C.o..'..Inc.....................................................................................
......... .... ....... ........
to Construct ( X) or Repair an Individual Sewage Disposal System
at No....................................... .............Lot 18.Jobvs .Lane Ostervi.11e
. . ........ ............
as shown on the application for Disposal Works Constructioi Street \�2 n Permit N Dated................. .......................
......................
0
........................ ........(.41ZL�.............................................
Board of licalth
DATE.............1-...1--- 0-1;z,
.............................................................
I
TOWN OF MAP . ...LOT `a7
20'MIN.
toP OF �O MtN. R ZONING : Ci. o�
FOUND. SEPTIC TANK.4--(�t715T. BOX�r 5ETBACKS: FRONT= 90- 510E-5� 10� REAR
i�- LEACHING FACILITY
ROUNO GOV E
—
�7 70'
GAL. 'S �� � ' —l'H,
• �� is 2 __-� ✓`' r, \. `;
SECTION— SEGJAGE I�IL.LIAM 2LJjAE�. - //1+ eo,
�yN Imo !1`%l%Q'' i '1• \ —I.LC L_�_I ,-j r
rEsr HOLE
LOGSD DESIGN FOR �,p�r���� fig"
TE5T er: I�Ow" _ CAPE, c,�.1C��1�F�,� F�IO VI�pDS��i "j
DATE : -f
PERC.RATEG2 MIN.//N.
- •- FLOW RATE ! IO GAL./DAY1%FI�
W/TNE55 r 1-i, SEPTIC TANK 350 (1,5)
-REQ'D. SEPTIC. TANK ,
LEACHING FACILITY
�;j 7 SIDE NALL '� � (2,5)=471,OwD I j D�X
w — BOrTom (io Z - Z�(;,d)-- 7$•5c-lo ' 9; ti
TOTAL 26 7.D 5F. - Glo . . 18� \ 40
Ij - .:. r rJG i
50 .
NOTES �, 4 �Qj �J n��°
I. DATUIy(M5L)t TAKEN FROM G0712'i QUADRANGLE AfAP !`
y,
- _ 2. MU1\11C1PAL WATER AVa1LA8LE
3. DE516N LOAD/NC. FOR ALL PRECA5T UIJIT5:AA5140-I Q-44
Q. PIPE JOINTS 5NALL BE MADE klA7ER TIGHT.
5. CONSTRUCTION DETAILS TO BE IN ACGOROANCE W1TN
CON".OF MA5S. STATE ENVIRONMENTAL CODE T/TL.E -Z
t �" 1 6, T1415 PLAN FOR PROPOSED !,WORK ONLY AND 5K0uL0 NOT
n' 6E U5FD FoR PROPERTY: L4. STAKING.
L . : / etc AR,� f
Cr v 4� a l
a
o t t// f
•e u , C.r `' � I Gt t`Clit(3.�.;yC(
d ti
1p�
O/OW/� CC] c� c�i'I h ol
LEGEND. T1E ! EtJAG PLAN
�„ ;��� P gll7ee�i q Locus : N
=��Z-�=k' I— —•. CoOUL' (Ex15r.>CIVIL 6NC,INE6R REFERENCE:
LANI UVEYOR5 (nROP)- o —` p I 157
DATE a4R LA-
CONC.BOUND Is CB PREPARED FOR:
92G Main st.Yarmouth Ma
"}�' c3+,��I� 1�•.! A�.3 1 7E57' HOLE Fl)0
board of health � I _
JOB NO. 8Co_G?O APPROVED: DATE. GS(ARI.� A SCALE . 3,1J DATE 7-31 Ofa
M