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HomeMy WebLinkAbout0058 KING ARTHUR DRIVE - Health 58 King Arthur Drive Osterville FIR 145 039 i F o 8 V . f TOWN OF BARNSTABLE '�G LOCATION q 11�7 h'4 SEWAGE 16P) VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ?,e5-re - yS- c3 y SEPTIC TANK CAPACITY !®Oa LEACHING FACILITY: (type) sZ h o® dAUers (size) I`.YO.OF BEDROOMS J' BUILDER OR OWNER 11 I- l PERMITDATE: o COMPLIANCE DATE: 0 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 E N � ` � tlY PERM N LO•CATIO SEWAGE IT O VILLAGE o �►�� � 1lle INSTA LLEER'S NAME S ADDRESS 1\ o642<r bua Co B U'11. DE R OR OWNER CA S (A) a a(,@ D e l DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED ; ..�,��_7 � Z a s C5T s= 3®` IA 30 �'t< �G �o f Commonwealth of Massachusetts Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form-Not for Voluntary Assessments F- 58 King Arthur Drive ' Property Address .� Sylvester Owner Owner's Name information is Osterville ✓ Ma 5/14/2020 required for every .. page. City/Town State Zip Code Date of Inspection `a l 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: A. Inspector Information filling out forms on the computer, use only the tab Chad hathaway key to move your Name of Inspector cursor-do not Hathaway Septic Inspections use the return Company Name key. Company Address Forestdale Ma 02644 City/Town State Zip Code town 774 274 2581 12866 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑. Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 5/14/2020 Inspector's Si ure Date The system inspector shall octor py of this inspection report to the Approving Authority(Board of Health or DEP) within 30mpleting this inspection. If the system has a design flow of 10,000 gpd or greater, the id the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts - ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 King Arthur Drive Property Address Sylvester Owner Owner's Name information is required for every Osterville Ma 5/14/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: This inspection is not a guaranteeand applies no warrantyof the described septic components in this report including but not limited to piping structual intergrity of components and life exspectancy of leaching and described components. This inspection is to describe conditions witnessed at time of inspection only. Regular tank maintenance and water conservation can prolong life of septic systems Information on care and do's and don't's can be found at town health dept or mass. ov 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts r� w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 King Arthur Drive Property Address Sylvester Owner Owner's Name information is required for every Osterville Ma 5/14/2020 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 Z Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts !� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 58 King Arthur Drive Property Address Sylvester Owner Owner's Name information is required for every Osterville Ma 5/14/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 f cam, Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 King Arthur Drive Property Address Sylvester Owner Owner's Name information is required for every Osterville Ma 5/14/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. I . ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 King Arthur Drive Property Address Sylvester Owner Owner's Name information is required for every Osterville Ma 5/14/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections-: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? E ❑ 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)] t5insp.doc-rev.7%26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 King Arthur Drive Property Address Sylvester Owner Owner's Name information is required for every Osterville Ma 5/14/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. 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 Description: 13'x25'x2' 2) 500 gal L. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to:. Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: unknownDate t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form 6-)i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 King Arthur Drive Property Address Sylvester Owner Owner's Name information is required for every Osterville Ma 5/14/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commerciallindustrial 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes_ ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: i l5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts rn s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �n 58 King Arthur Drive Property Address Sylvester Owner Owner's Name information is required for every Osterville Ma 5/14/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: tank older Dbox and leaching 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 12"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 24+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): no signs of poor venting or leaks. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 King Arthur Drive Property Address Sylvester Owner Owner's Name information is required for every Osterville Ma 5/14/2020 page. CitylFown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: .5'feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain) 1000 gal H10 tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8'x5' Sludge depth: 14" Distance from top of sludge to bottom of_outlet tee-or baffle 16" Scum thickness 12" Distance from top of scum to top of outlet tee or baffle 211 Distance from bottom of scum to bottom of outlet tee or baffle 8" How were dimensions determined? tape and sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): tees in place. Tank is at working level and needs to be cleaned as its overdue for maintenance cleaning t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 King Arthur Drive Property Address Sylvester Owner Owner's Name information is required for every Osterville Ma 5/14/2020 page. CitylTown State Zip Code Date of Inspection D. System Information (cont) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 King Arthur Drive Property Address Sylvester Owner Owners Name information is required for every Osterville Ma 5/14/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): Dbox is in good condition. no major decay or visable leaks. riser in place t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 58 King Arthur Drive Property Address Sylvester Owner Owner's Name information is required for every Osterville Ma 5/14/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts �n 119 Title 5 Official Inspection Form ' Subsurface Sewage Disposal-System Form Not for Voluntary Assessments 58 King Arthur Drive Property Address Sylvester Owner Owner's Name information is required for every Osterville Ma 5/14/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding; damp soil, condition of vegetation, etc.): Leaching chamber cover located and dug up. clean and dry sandy bottom. Leaching in very good condition 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts x - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 58 King Arthur Drive Property Address Sylvester Owner Owner's Name information is required for every Osterville Ma 5/14/2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont) 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY 58 King Arthur Drive V� Property Address Sylvester Owner Owner's Name information is required for every Osterville Ma 5/14/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 A2, s^y v �- G d G Q Q e p ; D /wig t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 King Arthur Drive Property Address Sylvester Owner Owner's Name information is required for every Osterville Ma 5/14/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 30+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on.record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: town GIS mapping You must describe how you established the high ground water elevation: lot el. area of septic is el. 42' low in area within 300 feet is el. 12' bottom of leaching is el. 36' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 58 King Arthur Drive Property Address Sylvester Owner Owner's Name information is required for every Osterville Ma 5/14/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 I �� No. t aaN0,1Y—Ya7 FEE 60 r� *,RBoard of Health, rn MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade•�4-Abandon( ) ❑Complete System Xjndividual Components Location Owner's Name ^ors vi vux o&.cA Map/Parcel# Address 5,ox 0^-e Lot# Telephone# Installer's Name' in.-s--mae Designer's Name Address g� a iP� Address ''Z (ZSs se.d aj D Telephone# Telephone# SUQj,.y--i7..5-3�-33, N 0 Z&kl( I?.- i i Type of Building 1?-5� ++Gt Q a as� �-r'.e w-�l l� Lot Size Z-�7( J � �'+—sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building / ^J 1 A No.of persons Showers ( ),Cafeteria ( ) Other Fixtures N/.4 Design Flow (min.required) gpd Calculated design flow 7 Design flow provided gpd Plan: Date 04 Number of sheets Z Revision Date Title �th• S< Q Description of Soil(s) 6 A } L j Soil Evaluator Form No. Name of Soil Evaluator P A-e LAt ate of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned a install the above ' scribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a ee not l until a Certificate of Compliance has been issued by the Board of Health. Si ed Date ie- Inspections No 7*^ �.((!t1lt FEE /o© "t7q• r tea. •�—�, . Board of Health, 4PLICATION FOP, DISPOSA* L,�y' ,ST[M CONSTRUCTION PERMIT. fl S] tv Application for a Permit to Construct(..) Repair(.) U.pgrade�4_AlandoilO - ❑Complete System ,Individual Components Location D �t Owner's Name G 1Nt 0,4, Map/Parcel# -`�a f ` - �' Address OX A^4 Lot# `' �. Telephone# Installer's Name A o2 Designer's Name h �1 ✓� ¢.Lf1,.t Address Qd Address, Z w, Crw s�u e,d J f 1 Telephone# �� �` Telephone# 508-y -A -5-3 1 Q ZGt'J" s Type of Building V-,-3,C/4-^-+-,u - J Lot Size el:7� s -J 7 4 4 sq.ft. Dwelling-No.of Bedrooms s /� Garbage grinder ( ) Other-Type of Building J IV I A r 1/ No.of persons Showers ( ),Cafeteria O 1 Other Fixtures iVIA {� Design Flow (min.required) gpd Calculated design flow Design flow provided?l rz7.7' O gpd a Plan: Date ( G I 04 Number of sheets Revision Date 4 Title �f o AfJ�C0 1% �C 1-t✓teams Y Ar� SS',1 ,L ..� A�lY�k-I 1 yN (` �� S �Cr mil. I mg P ( ) 6 —Go " A : L5 (0 "— "3� '` 13.1 LS /1 '�) 2U " f1 -- C Sa,,. t 4 Description of Soils , << Soil"Evaluator Form No. Name of Soil Evaluator Pe�\l�1 C- �te of Evaluation �� 2 (!Li DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agr,ens-to install the above escribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and furthe a ees to not o place a system operate until a Certificate o Compliance has been issued by the Board of Health E - lei. Si ried ) Inspections /i No. b U L� L" 0� FEE (} COMMONWEALTH OF MASSACHUSETTS Board of Health, R A -✓t MA. CERTIFICATE Of COMPLIANCE E , r Description of Work: �O Individual Component(s) 0 Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded k),Abandoned ( ) by: �^S r ! at Kt^fl I' or ('._C' Van i has been installedfin accordance with the prpvisi ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.. y" U dated !l v }L Approved Design Flow'c e2 a (gpd) t hlstaller Designer: Inspector: 4r kf" 44t Date: Rho 0 L/ The issuance of this permit shall not be construed as a guarantT,that the system will function as designed. N�W FEE /yy -� COMMONWLAL114 ®F MASSACHUS ETTS Board of Health, )3 G r 11 S fe,b U MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; ,Construct ) Repair( ) Upgrade( ) Abandon( )an individual sewage disposal system at 5� 1< A r 4 L"--y- C' MA --S i�rS yy)t A S as described in the application for Disposal System Construction Permit No,4--9- C?6q 7dated VIOIC' cr Provided: Construction shall be completed within three years of the da of thi e it. 1 local conditions must be met. , #st, Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date Uwy Board of Heal h� �; No..........7�- --- �1. _y Fps % ............... THE COMMONWEALTH OF MAS!iJ4tHUSETTS BOARD OF v.'H EA , :& H !��lax�.,.�...-..--.0 F.... Appliration for Disposal Works Tonstrurtinn rautit Application is hereby made for a Permit to Construct (P ) or Repair ( ) an Individual Sewage Disposal Syst at„ .... •Gam ... __...... Cam.. ................................' - .. a ocat ss ,/� or Lot No. P ....... --•-•••• . .....................-= ....................... ............"... ....................................... Owner Address Pq ............. ..... .. ..................% Installer ---' Address Typ of Building Size Lot__ ` - Sq. feet Dwelling—No. of Bedrooms.................___________________________Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type T e of Building No. of ersons____________________________ Showers a yP g -•--•---•------------•------ p ( ) — Cafeteria ( ) a' Other fixtures W Design Flow......... _Q__________________________gallons per person per day. Total daily flow.................,A ®_.O___..........gallons. Septic Tank—Liquid capacity�l�-C-tons Length................. Width................ Diameter________________ Depth............... W Disposal Trench—No_____________________ Wi th_________.____._ otal Length................._ ota ching area....................sq. ft. Seepage Pit No....../_1--4-ie.—Di s_______-___, Ole ching area__3_li__�_.s9,� ft. Other Distribution box ( ) Dosing to ( ) -0i �'� ' ��1' 7�-• 1"1 W Percolation Test Results Performed by-__._.. .Rol____________ ______ _� ..... Date____... Test Pit No. I................minutes per inch Dept of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.............. ,___ Depth to ground water........................ PG -•----••---= -- p O � Description of Soil...........-'---------�--�--�--i..__. z-..°JI--U�t-- -�`'r�__^---- --�--.--1'------ - 1 -r---- x V =•-"---------•----------••-•----------•------•-•---••---•-------•--------------------------------------- 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 iI'NU 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 by the board of health. Sign _ �Y ---•• ----'- ......................./Zs: Date Application Approved By....`• 6�r� ---------AK.._ ....................... � �� ��•"---- Date Application Disapproved for the following reasons:---"-----------------------------------------------"----""----------"-----------•---•••-•-•-•••••----•--••---••- ..-----•-------------•------------•---------•-------_---..---------------..._.._......---------._...__....__....__...._...--•-•--••••---••---•-----•---------------------------------•--•--•-•-••--•----- Date Permit No......................................................... Issued...V/�"� IV ...................•-•--- Date .............No 91 THE COMMONWEALTH OF MASSACHUSETTS -~� BOARD OF HE TH. ............................................. .....OF.... . App rFafilait for Dispaa al Works Tons#ratrtinn ramit y Application is hereby made for a Permit to Construct (0" ) or Repair ( ) an Individual Sewage Disposal st at �!oca d ss or Lot No. -t •--•--------------- OWn rr► �t,p /� Address k a ....--•- Installer Address d T of Building Size Lot.. = Sq. feet V Dwelling No. of Bedrooms �...........................Ex ansion Attic�-+ g— p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) � Other fixtures ;r' .�.°° ------------------•----------.-----------------------......-- ............................................................. Design Flow........,6".'�.V..........................gallons per person per day. Total daily flow.._................2-9_29.............gallons. WSeptic Tank—Liquid capacity �19'ons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. ................... Width otal Length ota ching area.........._.........sq. ft. r •�r'Seepage Pit No......... 1 -Dl fig' -- --_-_-- oyv > ••.... ching area--.''- - ...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by. ...... _C.2,�1. ....................... ate- -------- ---------------- Test Pit No. 1................minutes per inch— V*fst Pit _ h to ound teV' _.___ `___A_ _ 'j%� (s. Test Pit No. 2................minutes per inch Dept of Test Pit.................... Depth to ground water........................ i a ------- -------------•-------•-------..--•--------•---••----------.--•-- 0 Description of Soil................................. j x --••-----------------------•------------- ._...1 c . �+r1 ..... � ------------------------------------------=-------------------------------- ------------- 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 TIT E 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 by the board of health.' Signed _._ ._ Application Approved By______ Y- Date y Application Disapproved for the following reasons:.............•.....:.r.......__...___.__._________._.....-r. ...........................................----------------...----------••-----••--------••--------•------------------•--------•--•---------------------------......--------•--------------•-------- Date ' a .. Permit No..- :. =•--- Issued--........--•------- ........ --... .. _ ....3. ..... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH— , `'..... Grfifiratr l if ToutpliFanrr THIS IS TO CERTIFY, h t the vidual Sewage Disposal System constructed or Repaired ( ) by-----------------------. _ - ------ ••. •...... s '---_.--------- ..��ptt.._.. - --- J 'W Installer --- at •••... ... ............. .... ........ .. r' 't - :+ 4_e--------------------- has been installed in accordance the provisions of T F 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit 5--•• ......................... dated_-*-- __ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEAV H Fczs___`.�v............. F ............... Permission is he a anted.... -_ - .f;...__. _.... _ ._. .__.__. _ _ ..... , to Construct ( r e air ( n jndividual S wTa Disposal Sys A � ` at No............ p..... - � Street as shown on the application for Dis o� VCorks Construction Permit ._...... Dated. `, ' / PP P . ... 7"'g '/ �Boatf'He t DATE-----.t/ .. ............................................ FORM 1255 HOBBS &, WARREN, INC., PUBLISHERS - �EPi-!c T'!�►�ttC - 33b� iSo % � 4S�c7 cS.R17. { , .i .. A �' � s . � i '. � '� , �," ! ,. £ T� USA tOC?C3 64,L j [pELVAi.L �ieE.A. = l�jD S.F. . ! • , - ; � �So•j � b •�. ,, IOTA L IGI.1 v ES = -425 ti�, • , o f 1 x jj 4-.! s I�EtZGDt.QTIOtJ T'E Al•N, N~. i-.iiy .i'•.i i �aF r �.. � f`.R•�H-��till ��,i'{ P,�A6sA•f Jt-/.!,{9, ! +. � ' i i { j"t- it. OFVA lt,.ys - P�t41 OF 4• ��r {� / t r t r ,1 r 5 , , ,^f R!CHARD � y�. u�n . ALA[J c > � r, f l i i , f 1 2 f�c, OAXTER H JOP 1:: cn 21,048 No. c�3 l f i "lyy� SO 0 NAl TEST i j `G 9P 1, ToT o 7 ro .. ....ate• , + i nh �pe [�ONO IIN. • :� � 14 i � � 1 r�� , so B 4'PP� �tST tw. GAl 96.70 $EPnc , �• S , 94. uN j 1 TANK � ! ` (�d�. 9.�+'.00+. IN { t11V ,# � j t y- i fit• �. i.a trr � + -# xc !. ' f j GAL. Ls=acN f t ' s ,A «y PI i r! t f � t tom ) + , r� � � F.- i � •.• ..�,. i k-' i y �t - MBo f V./I-rw SA ND I } ' f 1 WAIWED CrPL./51..1 P2oF--t LE=— , l F r , LOC.ATIOV-4 ©sTERVIL�'t_ E - 2S.oc �',4Tt✓ N o v�/Are 2 rz/19/�7 1/ZIJWP 0 Plz0Posro � C�iZTII-=�f T�-lAT"� �'CI-1G FOUNtiA'T►oNStao,�c1►J F 1 ;,_� ` � P�--A1.1 ' 1 'TL�.F'i=2E►�1GE �; , at •.P.ci�m.i Gcrtt�L�(5: WlTI-; -rla 5r��..�1;►-tE- '' ; , ;}-� , l,.aT uTti o ; ; ' ,TO W Q 0r" C3 AiR N 5 T/i C3 t.._E •. { r , r f t t. , � �q� j ! lzeC.IS M-1ZIcD . fl- uevaYotZ4 f THI5 QLAt-1 I-S !•JOT 0SYE2VIl.LG t �l,t'�2J,✓�[_ .1; ,c y T G c.F SET', .5l1Gz�:J� A.V>pL. I C A ti1T CAPE',: 1'bE �EVEI; 'o wr. �r_.� .�c�_.:tca ��1�:ti�tit►�.(l='i 1..o-C' t I F-1�-,� • . •.,a•ss+w.....,..,..,,:.., i �__..._—�—� _.—.._.�.. ,._ -.., H t-•1! BHY 6Y9t k ql �.:�,rs �.. Town of Barnstable Regulatory Services 0 Thomas F.Geiler,Director nenusarLws i AM Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer&Designer Certification Form Date: L� Sewage Permit# Assessor's MaptParcel ` f 5 039 n (�2�,(l r't�, U�U\lX�nstaller: Designer: __ Y�0�� '' Address: J2 VJ CO) s 1 ail Y�4ddress: ?d_ ► 12�. on I 1 YO-SiW e E)) LAOcd)!�jn was issued a permit to install a (date) (installer) septic system at �� t't� ��-k yr ' CL—, based on a design drawn by y(address) / �UL V U-r dated C (d igner) �I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank I certify that the septic system referenced above was installed with major changes (i.e. greater than 10'lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or ce - gtitct follow. OF,y�ss 9� PETER T. tiG N o WE s mi er's Signature) " CIVIL ri . -o No.35t09 , Q (Designer's Signature) - (Affix Designer's.Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.doc TOWN OF BARNSTABLE C LOCATION g l<-1 1c'4 /4k t^-,iJ Dk, SEWAGE #2 Y— YD2 VILLAGE--- ASSESSOR'S MAP &LOT INSTALLER'S NAME.&PHONE NO. �As �"-G I q5 63� SEPTIC TANK CAPACITY .• LEACHING FACILITY: (typeYiZ h o® �� ��s (size) 1�iZX�'r NO.OF BEDROOMS BUILDER OR OWNER // PERMITDATE: a COMPLIANCE DATE: v 0 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 Feet 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 g /c:►A, 44 6-0r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL. PROTECTION h � 4 �i� Fyev FAILED INSPECTION . �n � - PARCEL, } Off` TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 58 King Arthur Drive Osterville MA. 0265.5 RECEIVED Owner's Name: John Hammond Owner's Address: Same MAY 13 2004 Date of Inspection: April 13,2004 TOWN OF BARNSTABLE HEALTH DEPT. Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my01p111111//1� training and experience in the proper function and maintenance of on site sewage disposal systems. I am a D ' -,w OF approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: •° °"•°' ��i,, s s Passes 3 ; O� TR °. T Conditionally Passes ° Needs Further Evaluation by the Local Approving Authority �` �� L� .�o XX Fails •`*ems Inspector's Signature: � A 11F Date: _4/13/04 PINS?�Gr�'e�'� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: Leaching pit full over top. ****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. Title 5 Inspection Form 6/15/2000 page I Page 2 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 58 King Arthur Drive,Osterville Owner: John Hammond Date of Inspection: April 13,2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health.. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 58 King Arthur Drive,Osterville Owner: John Hammond Date of inspection: April 13,2004 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 I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I Page 4 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 58 King Arthur Drive,Osterville Owner: John Hammond Date of Inspection: April 13,2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: F Yes No X _ 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 _ _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _X Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X Any portion of a cesspool or privy is within a Zone 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 forma _Yes_(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 _ — the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or,a mapped -Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 1 I OFFICIAL, INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 58 King Arthur Drive,Osterville Owner: John Hammond Date of Inspection: April 13,2004 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? 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 CM 15.302(3)(b)] Page 6ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 58 King Arthur Drive,Osterville Owner: John Hammond Date of Inspection: April 13,2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 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): Seasonal use: (yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2002 34,000 gal.2003—36,000 gal.=96 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMM ERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): _ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records: System has never been pumped Source of information: Owner Was system pumped as part of the inspection(yes or no): No If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X_Septic tank,distribution box,soil absorption system Single cesspool T 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 u _ Other(describe): r Approximate age of all components,date installed(if known)and source of information: Compliance date: 6/29/78 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 58 King Arthur Drive,Osterville Owner: John Hammond Date of Inspection: April 13,2004 BUILDING SEWER: X (locate on site plan) Depth below grade: 2' Materials of construction: _cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line: 40, Comments(on condition of joints, venting, evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) Depth below grade: 4" Material of construction: —X—concrete__metal__fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 8.5' long x 5.2' wide—1000 gal. Sludge depth: 14" Distance from top of sludge to bottom of outlet tee or baffle: 19" Scum thickness: 9" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom of scum to bottom of outlet tee or baffle: 8" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Baffles intact. Needs pumping. GREASE TRAP: No (locate on site plan) Depth below grade:— Material of construction:_concrete_metal__fiberglass__polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural-integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: 58 King Arthur Drive,Osterville Owner: John Hammond Date of Inspection: April 13,2004 TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: 5" 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.): Previously full to top. PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISP OSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 58 King Arthur Drive,Osterville " Owner: John Hammond Date of Inspection: April 13,2204 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: One 6x6 pit. leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields,number, dimensions: ` overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Leaching pit full over top Dug hole to expose access cover and hole filled up with effluent.Also had effluent breakout while probing for pit. CESSPOOLS: No (cesspool must be pumped as part of.inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): n t i Page 10 of i 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(.continued) Property Address: 58 King Arthur Drive,Osterville Owner: John Hammond Date of inspection: April 13,2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. �, 36 f M Page 1 I of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 58 King Arthur Drive,Osterville Owner: John Hammond Date of inspection: April 13,2004 SITE EXAM Slope Yes Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water : More than 15 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: X 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: Property to rear considerably lower than SAS. 4 CA LEGEND ow°y o 0 A6Oa 6 ° J ` 5 I 99 PROPOSED CONTOUR N Woy O 99 PROPOSED SPOT GRADE Nc''o Na�ha�s 40 EXISTING CONTOUR �C320�1'1 9S9 30.23 EXISTING SPOT GRADE a °P 6?, �% g S TEST PIT ROUTE 28 �\ 0 �F -- W EXISTING WATER SERVICall o EXISTING TREE a�'--D N 0� ��5 LOCUS—/ 0 LOT 8 APN 145 - 039 LOCUS MAP N.T.S. 9 9� = EXISTING LEACH. PIT. AREA 23,374± S.F.(CALL) TO BE PUMPED, FILLED 9 WITH SAND AND ABANDONED. . EXISTING 5EPTIC TANK. GENERAL NOTES: AN 4- t TOP OFT K EL. = 98. 13 INV.(OUT)=97.8± 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL 9 BOARD OF HEALTH AND THE DESIGN ENGINEER. 56 �, ;/"" g6 HALL CONFORM TO THE BENCHMARK: 2. ALL WORK AND MATERIALS S REQUIREMENTS W11E PAINT MARK —96 p01—_ s OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE LOCAL RULES AND REGULATIONS. CONCRETE SLAB I , E EL:97.47 (ASSUMED) Z DECK l �/ (0 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR (0 TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE o , EXI5TING *. �' mod' DESIGN ENGINEER. 0 J p --_12 BEDROOM 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 6? HOUS FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN -T.O.F. 1 ' 2.41 y ENGINEER BEFORE CONSTRUCTION CONTINUES. r \ 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. 6 THE DESI GN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF a THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 3 Ii HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. O a 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. N i� 8. THERE ARE NO PRIVATE WELLS LOCATED WITHIN 150' OF THE S.A.S. 9. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED m , TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. _ 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING CONSTRUCTION. L = 70.951 I 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS R = IN THE AREA BENEATH AND FOR 5 -FT. ON ALL SIDES OF THE S.A.S. 1 20 OO' AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR 255(3). KING ARTHUR DRIVE ����� OF MAsSq�y (40'WIDE) \ o� PETER T. PROPOSED SEPTIC SYSTEM UPGRADE McENTEE CIVIL No. 35109 58 KING ARTHUR DRIVE, OSTERVILLE, MA ` PSI Prepared Prepared for: John Hammond, 58 King Arthur Drive, Osterville, MA Engineering by: Surveying by: SCALE DRAWN JOB. NO. Y EngineeringWorks HOOD SURVEY CROUP 1'-30' P.T.M. 51 04 0 12 West Crosefie Rood 18 Route 6A 0 i r(� Forestdale, MA 2644 Sandwich, MA 02563 DATE CHECKED SHEET N0. �,Q I (508) 477-5313 (508) 888-1090 6/6/04 P.T.M. 1 Of 2 ,4 s NOTE: TO PREVENT BREAKOUT, THE PROPOSED TOP OF FOUNDATION PROVIDE RISER OVER D—BOX TO WITHIN s" OF FINISH GRADE F.G. EL: 92.Ot FINISH GRADE SHALL NOT BE < EL:88.5 (EXISTING) F.G. EL: s2.3t FOR A DISTANCE OF 15' AROUND THE F. EXISTING F.G. EL: 99.4t MAINTAIN 2% MIN SLOPE OVER S.A.S. PERIMETER OF THE S.A.S. EXISTING MAX. COVER OVER S.A.S. = 36" INSTALL RISERS W/COVERS OVER INLET 2-500 GALLON LEACHING CHAMBERS & OUTLET TO WITHIN 6" OF FINISH GRADE IN SERIES WITH STONE—ALL SIDES INSTALL RISER OVER ONE CHAMBER (MIN.) WITH HEAVY DUTY FRAME & L =36' L =13'(MAX) COVER SET TO FINISH GRADE. s" 4" SCH 40 PVC } 4" SCH 40 PVC d t0., 14" ® S= 1% (MIN.) 6" ® S= 1% (MIN.) ®®®$®®� -DOUB EE WASHER OF D STONE/2 a., a: EXISTING EXISTING 1000 GAL. INV. ELEV.=89:0 ®® ®®®® . ..... INV. ELEV.=89.17 2' EFF. DEPTH �_3/4"-1 1/2" a... SEPTIC TANK D—BOX WITH 3.5' 5.2' 3.5' DOUBLE WASHED INLET TEE EFFECTIVE WIDTH = 12.2' STONE INV.EL: 96.80t INSTALL INLET & OUTLET TEES (EXISTING) GAS BAFFLE TO BE INSTALLED ON INV. ELEV.=88.00 OUTLET TEE AS MANUFACTURED BY TUF—TITE, ZABEL, OR EQUAL TOP CONC. ELEV.=89.3 —BREAKOUT ELEV.=88.5 D—BOX SHALL BE SET LEVEL AND TRUE TO GRADE INV. ELEV.=88.00 ® ®®®®® ON A MECHANICALLY COMPACTED SIX INCH CRUSHED STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). ® ®®® ®®®asp BOTTOM ELEV.=86.00 4' 2 x 8.5' = 17.0' 4' 5 MIN. ABOVE MAX. SEASONAL EFFECTIVE LENGTH = 25' SEPTIC SYSTEM PROFILE HIGH GROUNDWATER ELEVATION LEACHING SYSTEM SECTION N.T.S. NO G.W. ENCOUNTERED pF MAss BOTTOM OF TP, EL: 80.5 �1� (3) 5" DIA.OUTLETS �P 9c4- 15.5" 16' �2„ o=� PETER T. McENTEE „ DESIGN CRITERIA v NoC135109 i 5.51, 6 NUMBER OF BEDROOMS: - 2 BEDROOMS SSr E� ,�, SOIL TYPE: CLASS 2 SOIL LOG I DESIGN PERCOLATION RATE: 2 MIN./IN. ( � D-BOX DATE: MAY 27, 2004 � p.`� .\ "*g SOIL EVALUATOR: PETER McENTEE P.E. RQe DAILY FLOW: 330 G.P.D. INSPECTOR: NOT REQ'D — CLASS 1 SOILS ? DESIGN FLOW: 330 G.P.D. (min.,req'd) GARBAGE GRINDER: NO Elev. TP Depth LEACHING AREA REQUIRED: (330) = 445.9,S.F. INVERT ®®�® ® ®®®® 90.5 A LOAMY SAND 0° .74 ®®®®® ®®®®® 33" 10YR 4/2 d SEPTIC TANK PROVIDED: 1000 GALLON (EXISTING) ®®®®®®®®®®® 24" ®R�®®®®®® !E3 90.0 6„ ^y B LOAMY SAND > 102'� — tOYR 5/8 h� s� USE 2-500 GALLON LEACHING CHAMBERS IN SERIES SECTION 88.0 C 30" SIDEWALL AREA: 2(12,2' + 25.0') X 2 = 148.8 S.F. BOTTOM AREA: 12.2' x 25.0' = 305.0 S.F. 4" KNOCKOUT TOTAL AREA: 453.8 S.F. 20" DIA. COVER MED.—COARSE SAND EXISTING: �� w ,, 4" KNOCKOUT O�4" KNOCKOUT 62" / ; " � "� `o DESIGN FLOW PROVIDED: 0.74(453.8) = 335.8 G.P.D. 2.5Y 6 s ;2 BEDROOM 4" KNOCKOUT 10-15%GRAVEL F10USE (No. 58) ��,,,, "''T.O.F. — 1 02.4 I "� �``� PROPOSED SEPTIC SYSTEM U �. P GRADE 0 P PLAN 77 58 KING ARTHUR DRIVE, -OSTERVILLE, MA 80.5 120 Prepared for: John Hammond, 58 King Arthur Drive, Osterville, MA 500 GALLON CAPACITY, H-10 LOADING PERC RATE: 2 MIN/IN. ("C" HORIZON) Engineering by: Surveying by: SCALE DRAWN JOB. NO. Engineering Works HOOD SURVEY GROUP N.T.S. P.T.M. 51-04 CHAMBERS NO GROUNDWATER ENCOUNTERED S.A.S. LAYOUT 12 West Crossfield Road 18 Route 6A NX.S. Forestdole, MA 02644 Sandwich, MA 02563 DATE CHECKED SHEET NO. (508) 477-5313 (508) 888-1090 6/6/04 P.T.M, 2 of 2