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HomeMy WebLinkAbout0040 JOBY'S LANE - Health 40 Joby's tane Osterville F/R A = 120 091 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I H 40 Joby's Lane Property Address Joanne Anderson Owner Owner's Name information is required for every Osterville MA .02655 12/20/11 .. page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in'any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information Ali on the computer, use only the tab 1. Inspector: ector: key to move your cursor-do not Ricky L. Wright . w use the return key. B & B Excavation,lnc. rab Company Name - 14 Teaberry Lane Company Address Forestdale a. MA 02644 " City/Town - State Zip Code 508-477-0653 S14595 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this addresss and that-the Q 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 onsite sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15,.340 of Title 5(310 CMR 15.000). The system; ® Passes . -❑ Conditionally Passes ❑ Fails - ❑ Needs Further Evaluation by the Local Approving Authority 12/20/11 Inspectors ignature 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•11/10 Title 5 Official Inspection F*Subsurfa: ewage Disposal�Ystem•Pagel of 17 r r ' Commonwealth of Massachusetts-Title 5 Official Inspection Form ` t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Joby's Lane Property Address Joanne Anderson Owner Owner's Name information is Osterville MA 02655 12/20/.11 required for every _ page. Cityrrown 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 r in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: , ❑ One or more system components as described in the"Conditional Pass"section need to be' replaced or repaired. The system, upon completion of the replacement or repair, as approved by . .the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound;not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND-(Explain below): e t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 t • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 40 Joby's Lane Property Address " Joanne Anderson , Owner Owner's Name information is required for every Osterville MA .02655 12/20/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 •N 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: El Cesspool or privy'is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1M 40 Joby's Lane Property Address - Joanne Anderson ;. Owner Owner's Name information is Osterville MA 02655 12/20/11 required for every - 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 aseptic 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 ❑ ZrLiquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow t5ins•11h 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 40 Joby's Laner s Property Address ` Joanne Anderson rx,. Owner Owner's Name information is required for every Osterville MA 02655 `12/20/11 - page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ' Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped.- El ® 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 El ® 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 For privy is within 50,feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet lout 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. f ® 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: r 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. .< �A Yes No x ❑ ❑ the system°is within 400'feet of a surface drinking water supply ❑ ❑ ,' the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead'Protection Area—IWPA)or a mapped Zone II of a public water supply-well } If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Joby's Lane Property Address Joanne Anderson Owner Owner's Name information is required for every Osterville MA 02655 12/20/11 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? E. ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM 40 Joby's Lane Property Address Joanne Anderson - Owner Owner's Name information is required for every Osterville MA 02655 12/20/11 page. Cityrrown State . Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] r ❑ Yes ® No Laundry system inspected? s ❑ Yes ® No Seasonal use? , ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a. g ( . Y 9 (gP ))� Detail: Sump pump? ❑ Yes E No Last date of occupancy: current ,. *•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? '° m , "❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 40 Joby's Lane M Property Address Joanne Anderson Owner Owner's Name information is required for every Osteryille MA 02655, 12/20/11 page. Cityrrown State Zip Code Date of Inspection D. System Information(cont.). Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection?, El 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 El Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous,inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained`from system owner)and a copy of latest inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Forth:Subsurface -Sewage Disposal System Page 8 of 17 P Y 9 Commonwealth of Massachusetts ' W Title 5 Official Inspection Form ; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 40 Joby's Lane ' Property Address ". Joanne Anderson Owner Owner's Name information is /11 Osterville • MA '02655 12/20 ' required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.). , Approximate age of all components, date installed (if known)and s_ource`of information: tank is original to dwelling leaching upgraded in 2003, Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.5 feet. Material of construction: ❑ cast iron ®40 PVC ❑ other(explain):. e . . . Distance from private w >15ater�supply well or suction line' feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection,building sewer appeared to be in good working,orderano sign of backup or leakage. Septic Tank(locate on site.plan): F Depth below grade: 1`5 feet • a Material of construction: ® concrete ❑'metal ' ❑ fitierglass' ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by.a Certificate of Compliance? (attach-a copy of certificate) ❑ Yes ® 'No ' y 5'2"x5'2"x8'6" Dimensions: a Sludge depth: l5ins,•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal S st m g p e Form Not for Voluntary Assessments Y- rY GSM 40 Joby's Lane Property Address Joanne Anderson Owner Owner's Name " information is required for every Osterville MA 02655 1 MOM 1. page. City/Town State.' Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" .Scum thickness Distance from top of scum to top of outlet tee or baffle 6' Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined?- scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): wl At time of inspection, septic tank appears to be in good working order no sign of back-up ,tee's present. Grease Trap(locate on site plan): _ Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ pol eth lene y y ❑ other(explain): Dimensions: Scum thickness r 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-1 Ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts ' H v Title 5 Official Inspection Form . 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 40 Joby's Lane ` Property Address Joanne Anderson t` Owner Owner's Name _. information is a required for every Osterville MA 02655 12/20/11 _ page. Cltyrrown State ` Zip Code Date of Inspection D. System Information (cont.) A 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: a ' ❑ concrete ❑ metal ❑ fiberglass ' ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: r. - ❑ Yes ❑ No" Alarm level: . rt Alarm in working order: ❑ Yes, ❑ No Date of last pumping. Date Comments(condition of alarm and float switches, etc.): r N 1 i *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•'11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments 40 Joby's Lane Property Address Joanne Anderson Owner Owner's Name information is required for every osterville R MA 02655 12/20/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert, 0 t Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At time of inspection d-box appears.to be in great shape, water level was equal with invert,no sign of carryover or leakage. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): ' If SAS not located, explain why: , t5ins•11/10 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 A. Commonwealth of Massachusetts . W Title 5 Official Inspection Form ae. Subsurface Sewage Disposal System Form Not for Voluntary Assessments 40 Joby's Lane Property Address Joanne Anderson Owner Owner's Name information is Osterville MA 02655 12/20/11 required for every _ page. City/Town State Zip Code Date of.Inspection D. System Information (cont.) Type `` . ❑ leaching pits number: , ® leaching chambers number: 2 ❑ leaching galleries number, ❑ leaching trenches number, length:, _ ❑ leaching fields 4 number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appeared to be in good working order, no sign of hydraulic failure.Water level was 1' below invert. 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 Y Materials of construction Y n Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of,17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Joby's Lane Property Address Joanne Anderson Owner Owner's Name information is required for every Osteryille MA 02655 .•12/20/11, 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.): 4 .. • E • t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r • 4 Commonwealth of Massachusetts . Title 5 Official Inspection Form n _ o Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 40 Joby's Lane Property Address , Joanne Anderson Owner Owner's Name information is Osterville MA 02655 12/20/11 required for every 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 • f 14 FC .. .. `. - i �y A3-3', A4/_33 ° e t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 ' Commonwealth of Massachusetts_ W Title 5 Official Ins ecti n F p 0 o rm Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments �M 40 Joby's Lane .f Property Address Joanne Anderson Owner Owner's Name information is Osterville MA ' 02655 12/20/11 required for 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 high ground water:,' >12 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: { 'Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 5 Commonwealth of Massachusetts ' u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 40 Joby's Lane Property Address Joanne Anderson ; Owner Owner's Name information is required for every Osterville MA 02655 12/20/11 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-11110 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 LCl (,� 3 DR �5T FL Evc 210 FL a � aR ow �� i - Oitu -7 - z JF �� 30'2 r A .Pu S Pe er Li r ff �is v`K q : .,,,..a�„a.•;., ww¢uv.^:=+s,s�.. a'..d:w.. � ..-.a-..:q,,,- •.,..�..xa �,.xTw„wst.•. -- - qj Fi € iq,, il 3yp e PIMP i' i gg e ` - qg s Kil - t - 3 W l � ' 1 i1 5 f i v. . o , s r k - P' � q i X. P v , 77 i e- 9c ECT-0 TOWN OF BARNSTABLE LOCATION 116) u �'�^��. SEWAGE #,�UG3 '91 VILLAGE Os/ery /C ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �600 661 (511V ilKs LEACHING FACILITY: (type) 500 G01 CAIAM �eJ Ca) (size) a � t3 NO. OF BEDROOMS 3 BUILDER OR OWNER kc PERMITDATE: I` 8c,41 5 c2co,3 COMPLIANCE DATE: 3 v Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by pr — as Pr � a B,a ' ` q //A, 3 �, No. LD / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0[ppYicatton for Zigozar 6pgtem Construction permit Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. )Ft c,�A:0 sheeti, Assessor's Map/Parcel d S%Cry /7Hi)1,20 �4sCtl / t n-J�5ls l.�1c C>P'K �-a Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. rucc Mc1 cc�l�;s► L(48_sj-aF col.,. 1D0-�/c AikrCr9<<r Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow .3.3Q gallons per day. Calculated daily flow gallons. Plan Date T A,v.3y -a0 0.3 Number of sheets Revision Date Title Size of Septic Tank 11 u0o 69/" Type of S.A.S. Q2? 5'00601 ,9!Z6-c/.J Description of Soil q�- Y`: SAno� /a A Al 13 m eo,,.,A, sa ng/ kS Z 54,,nj 1 g-,J dB u- 13a,y/h uJ.SN• Nature of Repairs or Alterations(Answer when applicable) RCmu L-c. 03i,r! 1 N9csr DST- T"Gc,c// ('HAM"J 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 Certifi- cate of Compliance has been issu by this. o d of He Signed Date ,ecll`� ? 00,�. Application Approved by Date 3 k 03 Application Disapproved for the following reasons Permit No. rX 0 f Date Issued S03 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) IM ^ DATA r>. No. lw, 3—o-7 — „ +.r. ^. .._� Fee Entered in com .terms THE COMMONWEALTH OF MASSACHUSETTS P -� _ Yes - PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Migozaf *pgtem Construction Vermit Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. - Owner's Name,Address and Tel.No. Assessor's Map/Parcel > 7y Installer's Name,Address,and Tel:No. Designer's Name,Address and Tel.No. U'vc� 1Yla„�c Il•,�i, � :7 /•� �,;• /! �t,wcr.t ! � Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ?j; gallons per day. Calculated daily flow 1 gallons. Plan Date j-o,?2,o 2 o a Number of sheets Revision Date Title Size of Septic Tank /,a°o 64 - 4:.{ ,J � C Type of S.A.S. Description of Soil 0,_- r)1 e,), itil 4,si 13 i 4,,)1 L3/)I }I f>._5,4,1y r Nature o€.Repairs or Alterations(Answer when applicable) Tc' )l (,r y 1j, r CA t rr / - ,)s`!;) Soo fF� 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 Certifi- cate of Compliance has been issug by this-Board of He t Signed g Date �PC/a403 Application Approved by t Date 3 &03 Application Disapproved for the f611 wl.pg Permit No. yt/U Date Issued 3 S 03 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired( Upgraded( ) Abandoned( )by _S/-'c c l,7 w n 1 at 1/0 5 >1 ti U a n rr- has been construct it accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2ws—09 11 dated ' S D3 .Installer 0 `l kC-CC11 , Cl_ Designer aRj«j,t The issuance of this permit shall not be construed as a guarantee that the systemty I�u t! Addsned.Date �i I�l!r,�i Inspector ,t No. 2 03 69 L ----------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS xigpogal *pgtem Construction hermit Permission is hereby granted to Construct( )Repair( t-(Upgrade( )Abandon( ) System located at L- (_:, _:�C:)\,�_�'� \ and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constr cti n must be completed within three years of the date of this 9e Date: S G 3 Approved by TOWN OF BARNSTABLE LOCATION Z10 U-u _ SEWAGE --91 VILLAGE s ASSESSOR'S MAP & LOT / � / INSTALLER'S NAME&PHONE NO. , / cLCC-./��>/e� SEPTIC TANK CAPACITY 1i00o CA/. �Fziri rr LEACHING FACILITY: (type) -a0 Goa/Cl/AM' rej Ca) (size) 0 �Pl . No. OF BEDROOMS S > . X t.3 BUILDER OR OWNER Tic Nqr-n, PERIvMITDATE: LA8C,9 t;`-c2oo_3" COMPLIANCE DATE: 3 v Separation Distance Between the: JW Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility (If any wetlands exist Feet within 300 feet of leaching facility) „ Furnished by Feet g g3 3 ' r � COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONM7,;NTAL AFFAIRS 4 w DEPARTMENT OF ENVIRONMENTAL PROTECTION G, - RECEIVED oW FEB 1 12003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION FAILED INSPECTION Property Address: 40 JOBY'S LANE OSTERVILLE 02655 t�k,( d C)C\ Owner's Name: RICHARD SHEEHY Owncr's Address: 40 JOBY'S LANE OSTERVILLE 02655 Date of Inspection:- Name of Inspector:(please print) JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET, MA. 02536 Teki:hone Number: 508-564-6813 FAX 508-564-7270 Cl!]?'TIFICATION STATEMENT I cc.:ify 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 _ Conditional Passes _ Needs Fur r Evaluation by the Local Approving Authority X Fails Inspector's Signature: / Date: 1>9w 1 103 The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspe tion. If the system is a shared system or has a design flow of 10,000 gpd or greater,ttte inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original shoult_I be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments THL SYSTEM FAILS TITLE V INSPECTION.THE LEACH PIT WAS FULL AT THE TIME OF THE INSPECTION. THE PIT NEEDS TO BE UPGRADED. ****"I'his report only describes conditions at the time of inspection and under the conditions of use at that time. 'I his inspection does not address how the system will perform in the future under the same or different conditions of w.e. Title 5 ln;nrrtion rovr'm (/15hM(1 1 Page 2,of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 40 JOBY'S LANE OSTERVILLE 02655 Owner: RICHARD SHEEHY Date of Inspection: tft l (i(p i 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: THE SYSTEM FAILS TITLE V INSPECTION.THE LEACH PIT WAS FULL AT THE TIME OF THE INSPECTION.THE PIT NEEDS TO BE UPGRADED. 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. n/a 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: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a 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: n/a { I Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 40 JOBY'S LANE OSTERVILLE 02655 Owner: RICHARD SHEEHY Date of Inspection: i r 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. _ 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 n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 40 JOBY'S LANE OSTERVILLE 02655 Owner: RICHARD SHEEHY Date of Inspection: -Wa D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: Yes No X _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] X _ (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. 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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. d r Page 5,of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 40 JOBY'S LANE OSTERVILLE 02655 Owner: RICHARD SHEEHY Date of Inspection: n/a Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health. _ X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS, located on site? X _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6,of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 40 JOBY'S LANE OSTERVILLE 02655 Owner: RICHARD SHEEHY Date of Inspection: n/a FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): wis o�(` — COD Sump pump(yes or no): NO $�)( Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a. Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records - Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a Reason for pumping: n/a TYPE OF SYSTEM X 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): n/a Approximate age of all components,date installed(if known)and source of information: 1984 Were sewage odors detected when arriving at the site(yes or no):NO Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 JOBY'S LANE OSTERVILLE 02655 Owner: RICHARD SHEEHY Date of Inspection: n/a BUILDING SEWER(locate on site plan) Depth below grade: 30" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN SEPTIC TANK: X(locate on site plan) Depth below grade: 24" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS" Sludge depth:3" , Distance from top of sludge to bottom of outlet tee or baffle:31" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle:3" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of leakage,etc.): n/a Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 JOBY'S LANE OSTERVILLE 02655 Owner: RICHARD SHEEHY Date of Inspection: n/a TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches, etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: OVER PIPE 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.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a R Page 9_of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 JOBY'S LANE OSTERVILLE 02655 Owner: RICHARD SHEEHY Date of Inspection: n/a SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology:. n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING. THE PIT WAS FULL AT THE TIME OF INSPECTION AND THE LIQUID LEVEL IN THE SEPTIC TANK IS ONLY 3" TO PIPE. THE PIT IS IN HYDRAULIC FAILURE. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): n/a q f Page 10 of 1 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARV ASSE;ISMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .! ')RM PART C SVSTEM INFORMATION (continued) Property Address: 40 JOBV'S LANE OSI'ERVILLE 02655 Owner: RICHARD SHEENY Date of Inspection: n/a SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference lanO,oarks or benchmarks. Locate all wells NN ithin 100 feet. Locate where public water supply enters the building. 4� pc As1 �1 ti in Pagc I I of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 JOBY'S LANE OSTERVILLE 02655 Owner: RICHARD SHEENY Date of Inspection: n/a SITE EXAM _Slope Surface water heck cellar allow wells Estimated depth to ground water 10+ feet ise indicate(check)all methods used to determine the high ground water elevation: NO Obtained from sysiem design plans oil record- If checked,date of design plan reviewed: n/a Vt;'; Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: n/a. Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: n/a i must describe how you established the high ground water elevation: HAND AUGER- 10+ FT. 7 0 C A T ION SEWAGE PERMIT NO. VII,LA C E INSTA LLER'S NAME A ADDRESS `. 3 <2 �a Z,,f /y? 1-4 v a U I L D E R OR OWNER ►c,`ignd �dCe ie,9 DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED f' �Z :.,, 1 s 11• © . FiS............._............•- �� THE COMMONWEALTH OF MASSACHUSETTS t BOAR® OF HEALTH ........................................:..O F.......................................--------------......-............................. Appliration for Disposal Murky Tonstrurti n ramit Application is hereby made for a Permit to Construct (V<Or Repair ( } an Individual Sewage Disposal System at: r TeW,Z��- L i ................_........_..:�. �.. ----L.�!u.�..�.�5 ��... - .......... Loca� - ddress or It No. .......................... .4. _.. .A3 ------------- y Owner ' Address Co,�►s.�u... .ir�A) ....M....... �� Installer Address �7 d Type of Building Size Lot..l5�_73..__.._._Sq. feet awellin No. of Bedrooms...._. ...............................Expans,,ign Attic (�d) Garbage Grinder (�t/0) p, Other-Type of Building .............7.............. No. of persons...?...................... Showers ( ) — Cafeteria ( ) a' Other fixtures --------------------------------- - ;3-• r ------- w Design Flow..........-�-.-,.? .......................gallons per person per day. Total daily flow..,3. ........................_...gallons. WSeptic Tank—Liquid capaclty.�®dU.gallons Length__ ...a/__-... Width..q_-.f_4... Diameter---------------- Depth.5..-_Z__.. x Disposal Trench—No- -------------------- Width.................. Total Length............i........ Total leaching area....................sq. ft. Seepage Pit No----_--------------- Diameter.._ ............. Depth below inlet................. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) _ Q 0-4Percolation Test Results Performed by._ALl_a3f' ... v V�''.,_ . ------------------..... .....minutes Depth to group water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fYi �........... --.--------i------.-..._ P 1 O Description of Soil....._. o.._.__....TQ....._..... . 1.G-......... C�� /V M ( - ?-I ,.............. x UNature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------•-•---------•---------------------•-•---....._......--•----•-•----------....---------------------------------------•--------------------------------.............•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL I'�U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue by t board �h. Signe . .. � � g�----- te Application Approved BY - = "l ��` y Date Application Disapproved for the following reasons:.•-•--• -----•---•-----•--------•••----••-----•-•--•---••-•----••--•-•-----•--•••---•----•-••-••.............•. --•-•---...•--•-•-•-•------------------••-•--•--•---••-•--•--•----•-------•-•••-----•----..._...••------•--....._.......•-•-•••---•------------•-----•-•------------•--•--••--•---------••----•......._. Date PermitNo....................................................... Issued....................................................... Date ---- ------------ ' r No-----`FS1.:d�U. 0 ........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH v". ...........................................OF..................................... Appliration for Disposal Works Tontratrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: j ., .......... ... e.b__�c.S..�: :...'.� ..--•--�.s.l�.......... e.._..... ........ ...................4--------...--------------.......---•----.......----- Location Addres r Lot No. ........... r 7® .t....�? - cY�!L ----- Owner 1dress GG �� .. ........... t a zt .....cju.14'Tru IS! :?.............. .......... Z... '© '�9 L NL--/------- v� Nl---- Installer Address Type of Building Size Lot............................Sq. feet U Dwellin - No. of Bedrooms............ ..........................Expansion Attic (/Vo Garbage Grinder (MC) Other—Type of Building No. of persons...... .................. Showers Cafeteria, ( ) Otherfixtures -----------------•------•--------------•--------------.-------------------•-•--------------•-----•-••---------------- Design Flow . _ ._ _ gallons per person per day. Total dail flow__ .. ............ gallons. w lm -- -- ---------•-•g P P o Y Y W Septic Tank—Liquid capacity-_1!q ..gallons Length__ _.. ...._.. Width Diameter---_--__-___. - DePth................ T........ 0 7 V x Disposal Trench—No...........�....... Width.... .............. Total Length.......b..... Total.leaching area�________.......sq. ft. Seepage Pit No..................... Diameter.........(;.._------ Depth below inlet....---......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation Test Results Performed by.......................................................................... Date-•--....-•------ ...-•••-------------- Test Pit No. I................lninutes 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......................... •---•----------------------------------•-•---•....-•-•-----••--••-•---------.........---....-----.....---.................................................. 0 Description of Soil................--•-------------•-------------------...............---------•-----•---------------------•-------- .................................................... x w 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in— operation until a Certificate of Compliance has been issued b the bolo health. Sign ..--•........ ..............•---...------------ `�_IG �U r / f ------- ate Application Approved BY ......--- ••---- ...•= ......... - .................................... ... ........... f Date Application Disapproved for the following reasons:••--- -----••-•--•------------•--------------------•-•--•-•----•-------••-•--•------•-•---•--•------....------ --------------------••--•-•••----•------------•.....---------...••-•------•------•-••---•--•-•----------•--------•--------------------•--•--------------•-------•-----------••-----------------------••- Date Permit No......................................................... Issued------------------ ---------------------------•---=---------- Date THE COMMONWEALTH OF MASSACHUSETTS t BOARD OF HEALTH ..........................................OF............................................................"'l.................... At wr#ifiratr of Tootplianr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) b c.................................................•-------•---.........--•-----•---•-------.........-----•-------••---------••-•--.......---•--•--•--- Installer L has been installed in accordance eitihthe provisions of TIT LE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......._._----:=_16.................. dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................................••. Inspector........ 5 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF....................... -' No..... ......... FEE............�)......... for �o trt ion amit Permission is hereby granted............... --•-•- � =`^ r----------------------------------.......---------......------.....----..._ to Construct ( ) or Repair ( ) an I dividual Sewage pD.i. ,posal Sys atNo. -•-----------. ----L.1 - ........... f.�'' 1 �� ......----- ------------------•------•---•--•-----•-----•- T Street as shown on the application for Disposal Works Construction Permit No./.................. Dated.......................................... ------(<................................................................... Board of Health DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON { APPLICANT' � �� � FEE__�D« j_i)DRI;:SS�_.—_.—__._._.._---_- -._-- -- —:— TF'L:EPI ONE` NO --- -- (Non-refundabi, TEI,EPHOLNE NO. ll?.TF. SCr[F''D*(J-C,.FI:)-..- —(P_pplicant' s signature) . . . . o , , . . . . . . . . . . . . . . . . . . . . . a . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SOIL LOG SUB-DIVISION Ii M_ 1, Dr.`1'Ii �� TIME F'`�t�_�.NSION AR�'A: Y'ES�NG '[ ENGINEER TOi1iN WATErj/ PI� Tv-,,TE, 6vE.LL—� G — BOARD OF HEM,' 1_- � � EXCAVATOR SKETCH: (Street name , etc. ,dimensions of lot, exact location of test holes and percolation tests , locate wetlands in proximity to test holes ) ;' . . NOTES : -tea. Joe PERCOLATION RATE :' .TEST HOLE NO: E EVATION: TEST HOLE NO: ELEVATION: 2 f 00 TbP &7I� 1 2 4 �i•1. 4 _ 8 J�1D 8 9 9 10 10 ---- 11 11 --- . 12 _ 12 -- 13 13 15 15 ---- 16 16 SUITABLE FOR SUB-SURFACE SEWAGE : LEACHING FIELD XLEACr.L_�;G Pr us, us, LEACHING TRENCLFf UIdSU ITil-BLE FOR SUE-SURFACE SEWAGE . REASONS : --__ ilU�in ✓.i?. aSS!"G TE:D ONe' F: TESTAPPL:IC-.,?IObi r TY BY P i".} F i "i y� '`F : F/�t//S// FG ODR EL 3L.3G - SO/LS TEST RES'UGTS . SEWAGE SYSTEM PROF/L.E �'> _ _ SANG y a 4 F/Nlsf/ G�'ADE M/N. •SL_OPE C"MAX- 3G"MAX. G•'MAX. 9" MIN, �fILL� 2 MI BOX Lc/ G S[/MP /A/V. 3/,gS 3G MAX. 2' C011 t .. i o /2 `M/�/. /NrV.ERR MEAS!/.eE �.. ., o� �4 — �2 STOn/L /3 SANo)' GoAIy 5c H. 4o P vG OR/G/NAL A �•/• 4.0 PVG cJ/d `L Et�E13� 3 Sc `, SC H. 4d PVC D //✓V. /z ✓. WI NN. /it/v. /Nv. /N V. 3/ .�— l`/z' 1• •. i 2/" ToPSo/L_ 33.08 32.78. 2.53 32. /7 32 oo WAswEo L49.4 4, G L"QED eF WASHEaa o a +� /+ //z STONE sToN 2• EFFEC77VC-Cl2USHE_p .•. . o e o oe (2J 5006. LE�9CH CHAMBERS •°o •moo ,B 0 0 STONE o ON b oD )=7 Ci Q ' , Q G7 � o u.oo�oo I Z8� W/ROY)TS E� 32 .0 EX/sTXVC /oo o 0.P2EC,4Sr SEPTIC 7XNK SO!/S A,85aRR T/d�c/ S ySTEM SA//.D • EL Z 3. � �. ,BoT'T oM of TEST GRouNDwArE/f NaT �.vcov�YT�.eE,h SO/GS 7EST-0.4725 : 2- �, - 03 SO/L S EV.4L UATOR TwgaHEo STONE 4 �X -4 V-4 O/Z = ,2!/cE CALL/S7�G T 8 M /r 4• 2 E C. A . P lC 1 z 1O 5.00 6. Ch//4MBE!'S P R /� 7E S M/N E.e / h� 3° 4' _ . /l/ 7d ° _� `}' WASH E� 370 NE L FL AM VIEW OF S.A, 5. $CAGE = L O 7- /�/D. 2 2 /.6, 737 S. /= • ! AsSEssoRs SAP /Zo PARcE� 9/. ' L 30 SELt/�9GE sysTEM -DES/6A1 Cq<eal- Vr/DNS !� 0 y h a 3 BcORODMS X //O \ . �d L 0 2. /eEQU/.CEO A.BSOIPPT/Dh/ A�PEA = -��, Ocus � 3 O 6 ,0 - O.7 G SF -D-4 = .P o rj P ,r1 ay ev W TMd �2� s"oo s. pRECA S T LEA C!/ Cf/.4M8E,2 5 v Rio W/T// -f' OF 7N/!CE WOSW25-D -1 0AIE Af�OU/�1D, S's'f'i F y h - _p ,BorToM AREA /2.�3 x 2S 3Z0 s a : v AREA CZ5.G SO� X 2 /5"/ h TOTAL' = f 7/ • / , y S 3 S•o � � Of v SORB Rio 5 sow 0 • / S /ST J / 0 lS1 �X o �' • OoYV-.M O Box l D p 1 It ' ti Q' 0 Na.sf3ssr L O CL/S /�AP �-C.4L E • / .30 00 � /8 s�P�x h 3 p t SE W.4 6 E S Y,572W UP6,0R q O E AGA/N J�• w ST T ( T . x/ pl 9 S )LEf� vl i (� /'REPA/2ED FDA tj -- Z. Z8. oo " r G.4, PV --- x , � D 2 E C E� CEO EG L N6 - _„ 32 • "'�! WIC_ .•1 _ ' �, _ Ti9.BL E 1 ERMht: -, ,�i9/QNS � � LIES , Na 23971 �� • w .5 41.E• 20 ✓AN//ARy 3 0 200,3 , MAL O 4D , . ✓. O /AYES 7�L a •S63• /99•¢ .h YLE ASSDG _ _. r a i q' s' INLFT KNOCKOUT -- 1 1 ` _ .:• j DUTY-'� ;,1�ET y : 1 /•'•• • _ _ 6 Y 4 DIA KNl7rK )L!T,j 00 I J iUt O �_ c � °0 �- s3.� _ . . 7-1 ., SEWACE YSTEM �RD�"/30 C o 0 0 0 o C O � ' c „ _: 5',;,r ; 10 a0 O - - ---- -— ------ -- - - p �✓ � OOO lJ G p O A?ADF J'0 p O O O O Q 4�00, 6 s xs" G'G k'� .�"f30 X DIiER L EACh�G'/T t . - � 10 po 0000 ° Co o d� ,- e;l: 00000000 j� �.. o 0 0 0 o �. - 4 11 .r O O O � Oi- 9 Q -.-.ems_..,...-•...- __ _. - _ .t,_..�r if - f)i, T" Ai �(%;; � / 0 V 0 0 0 0 0 0 Q I' a'-o 4'-s' ��s T Box �9�p� Q Q 0 0 0 0 d a m ® 0 0 3" LEVEL , r 40 ._ .- / / -, _- - �Y V O V ® © 0 O V I1 L .. .��', .«/rV- ;�.:, sir / �,v�L - 3,r 0 ® Y/Tati J :1 0 0 o 0 0 0 0 0 01; 0 L� T ; G'EA/.ERAL NOT55 ,� ,�O/L 5 LG�S 1 'i 0 0 0 0 (D 0 a p 0 0 0 �' I (ra f I , I PrT / �� 2 ;" 00 0 0 CD 0 (' 0 00 0j; t{ .4LL EL�QriD�vs sh(�wry .�•�� ,�.. - Ad.G4/V SEA ILE: ze� •'�.`.. :c ;r: - �� J ,! 0 0 o 0 0 �© 0 00 0 j, 1 II 2 . ALL -- ' � ' U C,457-I�Or�/ OAP SL�IEL7,L/L,�: 40PIC ��=�i�=�;%-�,: OES/G/t/_ CR17ER/,4 AZL &IN�J/Ti1 BL E*97Z /,4L -- `± BEE/EAT 4 7/--"IAIVERT EL2FVA7701V (/UMBER O,4:-BEURODA1f5 L PE�SOrVS PER f3�O.PODit�1_ __ FF s CLEAA/ �0,4,P�c GRAiI/(/LA,P<I 1 X L EA /7,X1 Tf-/E --- - + /5 liV57AL L ED PX�0/F' TO CA/-cy1-A 7-10A15 /rVC FO,P IIv5,aECT/OIV ,��RCOL,4T/D�c/ ,,�AT,c`� `'• A'l/N//�c� &WZASS 0717E. WISE NOTEO 00 ALL .'3r`.?4,(, r �`30ARD D�f-�EALTL/ 5/QE - T1�!-/ _ 377 v S Y5 7Z C04/POit/2 N 5 -5, 4L Z- f3E L�4 C 3•�� •7`� i 11V57ALLED Al/ ACCOlP2?AiVCE 411Thy /. —7-4_, - t ; ACH + 4PPZ1CA MAS T!rLE -7 54N/TARE x -5zFWER FA cC- _ UL `j .4<JGb5, 9W,FL L/iVG'LOC-4 7/- 0/V A" A"X K/f•�/C--1 �t A y BE APPL/CAE3L E J PROG'O5ED` -5,EWAG.E 5 YSTEM ZOc,4T/Drv' 6 . Ti�1/SLOT/S - ._ F_. DOO GYA/�/ ___ 7_ A GARBAGE C RAVDER W/L L /NST,4LLED Dit/ THE SYSTEM. <``�r�.�'�1ST�98L D57'�RU/L L e ) j "A 55. L E'GE Al D SATE : S, 46 �r ,mil L L CA C'f= _> �!�I/c Y C011,15 L 7A