HomeMy WebLinkAbout0029 LITTLE ISLAND DRIVE - Health 29 LITTLE ISLAND ;
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�-Vj,ILLAGE .M'rt!-Ot(- ASSESSOR'S MAP & LOT y 3 s SS-1F 0�
INSTALLER'S NAME&PHONE NO.�!D&C--en �(2-
SEPTIC TANK CAPACITY 1`Staff C�,A'L
LEACHING FACILITY: (type) Lya"c►, fv.� Ill.e,1ek (size)
NO.OF BEDROOMS q
BUILDER OR OWNER P, S,CuL
PERMTP DATE: K-to-5' COMPLIANCE DATE: t 2 <o-9 7
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 ti
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TOWN OF BARNSTABLE "�
LOCATION ag !P i7fZ, Zd i 0 8 R SEWAGE # ;400 70
V?I,LAG �lrti '� ASSESSOR'S MAP & LOT9 3-Y r
INSTALLER'S NAME&PHONE NO`�� �O Z 3®�-f to N�
SEPTIC TANK CAPACITY,
.,LEACHING FACILITY: (type). V-k ,a /Pl�l®k (size) A0,X a4,
NO..OF BEDROOMS .3
BUILDER OR OWNER fir" r, 13ADK0,
PERMTTDATE: —_:.CqMPLIAN4 DATE: 4✓
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet 1
Private Water Supply Well and Leaching Facility (If any wells exist 11
J,,%jon 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
Furltished by`- K•ek
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 29 Little Island Dr. (Main House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osteryille Ma. 02655 5/27/2010
every page. .City/Town State Zip Code Date.of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms the
computer,
r,use 1. Inspector: (//
only the tab key
'
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
r� P.O.Box 763
Company Address
Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Furth valuation by the Local Approving Authority
i
5/27/2010
Insp t s SI n re 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.
/I
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syste Page 1 of 17
y.
Commonwealth of Massachusetts
L Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Little Island Dr. (Main House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in porper working order at the present time.
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):
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 29 Little Island Dr. (Main House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every 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
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 29 Little Island Dr. (Main House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
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 a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria 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
ElBackup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins•09/08 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
�M 29 Little Island Dr. (Main House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every 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:
❑ ® 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.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in.310 CMR 15.363, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 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
;M 29 Little Island Dr. (Main House)
Property Address
Elaine
Markey
.
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® 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): 5 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
t5ins•09108 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
29 Little Island Dr. (Main House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2008:56,000
g ( y g (gp ))' 2009:45,000
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 5/27/2010
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: .-
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 29 Little Island Dr. (Main House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. CityFrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® 1Septic 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):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 29 Little Island Dr. (Main House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osteryille Ma. 02655 5/27/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
Approximate age of all components, date installed (if known) and source of information:
Installed in 2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 14"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ 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
Dimensions: 1500 gallon
411
Sludge depth:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 29 Little Island Dr. (Main House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every 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 28„
Scum thickness
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
13"
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.):
Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/0, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Little Island Dr. (Main House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
`Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M01 29 Little Island Dr. (Main House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has three outlet Iaterals.No evidence of solids carryover.No evidence of 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M0 29 Little Island Dr. (Main House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
12'x50'
❑ 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.):
Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil.Leaching field was dry at time of
inspection.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
_ I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 29 Little Island Dr. (Main House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every 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.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
RE Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
29 Little Island Dr. (Main House)
Property Address .
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
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
s 3 �
70
3 z7 3 a
? rLs�
. � 7 �q
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Little Island Dr. (Main House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. Cityrrown 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: Bottom of LF 5'
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:
As-Built
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report:, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
l
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Little Island Dr. (Main House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 29 Little Island Dr.(Guest House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osteryille Ma. 02655 5/27/2010
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms the
computer,
r, use 1. Inspector:
only the tab key
to move your Robert Paolini J
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
t� P.O.Box 763
Company Address
Centerville Ma. 02632
0! Cityrrown State Zip Code
9508)428-4028 S14454
Telephone Number License Number
B. Certification
I certifythat I have personally inspected the sewage disposal system at this address and that the
P Y P 9 p Y
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310.CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Furt r Evaluation by the Local Approving Authority
ti
5/27/2010
Ins rs Ignatur 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•09/08 Title 5 Official Inspection Form:Subsurface Sew a Disposal Syster age 1 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Little Island Dr.(Guest House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osteryille Ma. 02655 5/27/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
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):
l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 29 Little Island Dr.(Guest House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. City/Town 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 FIND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Tit
le 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Little Island Dr.(Guest House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*" This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/day flow
t5ins-09108 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
M 29 Little Island Dr.(Guest House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osteryille Ma. 02655 5/27/2010
every page. City/Town 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:
❑ ® 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.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd:
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 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
29 Little Island Dr.(Guest House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
330
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
I
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Little Island Dr.(Guest House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2008:56,000
g ( y g (gp )) 2009:45,000
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 5/27/2009
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M •''v 29 Little Island Dr.(Guest House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every 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? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
- _ I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 29 Little Island Dr.(Guest House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1'feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
Depth below grade: 6"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ 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
Dimensions: 1500 gallon
Sludge depth:
2"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Little Island Dr.(Guest House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. CitylTown 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
30"
Scum thickness
0"
8"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
14"
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.):
Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
29 Little Island Dr.(Guest House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Cisterville Ma. 02655 5/27/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
`Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 29 Little Island Dr.(Guest House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every 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 No
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.):
Box is Ievel.Box has four outlet Iateral.No evidence of solids carryover.No evidence of 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM , 29 Little Island Dr.(Guest House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
20'x25'
❑ 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.):
Sandy dry soil.No signs of hydraulic faflure.No ponding or damp soil.Leaching field was dry at time of
inspection.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-09/08 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
�M 29 Little Island Dr.(Guest House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. City/Town 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.):
Privylocate on siteplan):
( li
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Little Island Dr.(Guest House)
Property Address .
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
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
2®,
3� o
t
qy.4n
r
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Little Island Dr.(Guest House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville . Ma. 02655 5/27/2010
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: Bottom of LF 5'
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:
As-Built
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
I
Commonwealth of Massachusetts
Nwm
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
29 Little Island Dr.(Guest House)
Property Address
Elaine Markey
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. City/Town 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
i
No. c2=:f20-7 w- .. . .i —,� Fee—F —
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS s
01pprication for Migpogal *pgtem Cow5truction 3permit
Application for a Permit to Construct(L Repair( )Upgrade( )Abandon( ) LRJComplete System - El Individual Components
Location Address or Lot No. a Q L I rrIFF 45L AIND lP, Owner's Name,Address and Tel.No. 7v �jY5
Assessor's Map/Parcel 65T9�V'� 13j4L fnl, kRKE f C� !�jo�1"`0 4�
43 U S,• 0OS-
Installer's Name,Address,and Tel.No. Y ) a/5
3 � `
DZesigner's Name,Address and Tel.No. [�/
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size SG, 9 3 sq.ft. Garbage Grinder(All))
Other Type of Building!!WD FX/4140 No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 0 gallons per day. Calculated daily flow 330 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank i 500 V ALLOAl S Type of S.A.S. W,1 S#-9,6 5rd wE 'F I EL D
Description of Soil QS PCX h''AXI
Nature of Repairs or Alterations(Answer when applicable)
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 iss by this ealth.
Signed Date
Application Approved by Date 2l— 2Dt�
Application Disapproved for tYe following reasons
PermitNo,_ �aQW :7n 7 Date Issued Z t` b —"f7&251�
y Fee��/�)�.
=ENO. 411)--7U"7
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ;!
-- 01pprication for Migooaf *pgtem Con.5truction Permit
Application for a Permit to Construct( Vj Repair( )Upgrade( )Abandon( ) Ekf!omplete System ❑Individual Components
Location Address or Lot No. a2 if LIME I_%/6VD IX Owner's Name,Address and Tel.No.
Assessor's Ma /Parcel s�' JN 4 L m 4 2/eE Y 77/-/010
p �t3 0 SF. v0T-
Installer's Name,Address,and Tel.No. O! s� Designer's Name,Address and Tel.No.Q
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size 56, 9 13 sq.ft. Garbage Grinder(,<!o)
Other Type of BuildingU%QD r.-4ME No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 33 0 gallons.
Plan Date, Number of sheets Revision Date
Title f
Size of Septic T k / SU4 < gZ4-0A1 5 Type of S.A.S. UJtf Sft.456 5r0,0t/E' F I ELD
Description of Soil OS ALHiv
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: j
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 iss by this 7d, ealth.
A/
Signed Date
Application Approved by Date
Application Disapproved for tWe following reasons
Permii No,_,-)CX]L) — D-7 Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage spos ystem Pnstructed( ✓Repaired ( )Upgraded( )
_Abandoned( )by
at oZ 9 J/T 7L E 1 S L A n/0 Ole, o 5 i E!x i/IL.LA has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 0000-7 67 dated I 0/o.
Installer Designer
The issuance of this p 'tgsall not be construed as a guarantee that the syst 1 fun o s signed
Date 6 Inspector
No. ���" 7U� ------��_s—��---------------Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
1=i!5po!5ar *pgtem Construction Permit
Permission is hereby granted to Construct( VSRepair( )Upgrade( )Abandon( )
.System located at 129 4 /TrLF— /5 L j-Vb D12, D5 TE2✓I L.L. '
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:Construction must be completed within three years of the date of this permit. c �
Date: I!1- Sts'- G��/d� Approved by
ET' -
y .+•¢' -- ..,c n r i iga 1 �• t K t .•z.--_rr�3`
7 IL"t -gsTh K• '��r '..x4,j Ell
a- �'•,�-x •4 ASS " cJ L;'.^"
oo
TOWN-OF BARNSTABLE a
LOCATION 14 Lim, 1�h�id R ..;<: r .SEWAGE # )006""�.707
VILLAGE gmerI[D ASSESSOR'S MAP & LOT 3'S ;..
INSTALLER'S NAME'&PHONE NO. 30D�U �iricN�PJ
SEPTIC TANK CAPACITY -
LEACHING FACILITY: (type) ��� �iS/r��l®it �i/rt' (size)
NO. OF BEDROOMS 3
BUII DER OR,OWNER Sr e. L C�-lJ.
PERMITDATE: D COMPLIAN DATE: 4/
-
Separation Distance Between the:,
Maximum Adjusted.Groundwater Table to the Bottom of Leaching Facility . Feet
Private Water Supply Well and Leactung Facility (If any wells east .
�on'site or within 200'feet of'leaching facility) Feet
Edge of Wetland and Leaching Facility(If any;wetlands east
within 300 feet.of leaching.facility)
Feet
FdEpgished by
44
r
13 4
1 .
r
r
ASSESSORS MAP NO:
No.- w`=-----�- - PARCEL NO: �?- CSt:, Fe ---- �- ---------
BOARD OF HEALTH
TOWN OF BARNSTABLE
App[ication-*rVell Con0ructionPermit
Application is hereby made for a p�e it to Construct �), Alter ( ), or Repair ( )an individual Well at:
0(c q: 1' .I.S/�v
---------------------------------------------------------------------------
Lo anon — Address Assessors Map and Parcel
- - - -y-- ---- -- -- ---- --- - ----- -- --------�----�---------- - -
/ Owner Address
/--------------------------------------------- a C �/ -----------------------
Installer — Driller Address
Type of Building
Dwelling-----------------------------------------------------------------
Other - Type of Building-------------------------------- No. of Persons--------------------------------------------------
Type of Well—y -Pt�C - -- - --- - - - Capacity-------------------------------------------- -- ------------------
Purpose of Well-_1_f� La-tto='*------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions,of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees',not to
place the well in operation until a Cert' icat .of Compliance has been issued by the Board of Health.
Signed - -- -- - -- - -- --- -- -- - --
date
Application Approved By —E�'!� --------------------q------- -J----- �- -- --------------
L'` date
Application Disapproved for the following reasons:----------------------c------------------------------------------------------------------------------
----------------------------------- -------------------------------------------------------------------------------------------------------------
, � �,j / date
Permit No. --1'v 7,��--"—��----- -- - Issued-----%-R-�6�- -------—-----------------
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( 11, Altered ( ), or Repaired ( )
by------------ ---� C y N ti 2 ---
----------------------------------------------------------------------------------------------------
]�/� Installer
at-- �_ _ /�"/��_'�-�-- P�S-L`c/��//P-------------------------------------------------------------------------------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit Nok/ Dated-1--- -----19le
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE- --- --—----— - ------ -- Inspector----------------------------------------------------------------------------
1 ,
� 7 Z:177
No.— — < ® � Fee --- ------------
I30ARD OF HEALTH r �
TOWN OF BARNSTABLE tJ«
0ppCicationArlDell Cootructionpermit
1
Application is hereby made for a pe it to Alter ( ),coVFl ep iir ( )an'individual Well at:
Lo ation — Address ' Asses and Parcel
• Assessors Ma P� �
--�" �� J �t �P s G•� A/ 6S/` car l/p
o� r r/
--� — —------------— --- --- —— — �— — `— — - — —— — — --
Owner / Address
Installer — Driller Address
Type of Building
----------------------------
Other - Type of Building--------------- ----------------- No. of Persons---------------------------
Type of Well— -pJ G- - - - - - , Capacity------------- -- - - - ------
Purpose of Well--�'—��-'--'"�G-�-/�"�_-----------------------�-� I�
Agreement:
The undersigned agrees to install t e afo�described i ividual well in accordance with the provisions of The
Town of Barnstable Board of Health tit
Well Pro lion Re e�{lation — The undersigned further agrees not to
place the well in operation until a C rt' icat .of Co fiance"has�t3eerssd by the Board of Health.
Signed ---------------------------___---------- ---- - --=-------------------
datte"�--
APplicatio Approved -y — - — ---
--- date
Application Disapproved for the Following reasons:--------------------- --
-., ------ — -- -------------- ---------------------------------------------------------------------------------------------------------
" date
/
Permit No.--#'!--�-/_��°'✓ ---------------- Issued--------��---------�-------- -----------------------------------
date
BOARD OF HEALTH
TOWN OIF BARNSTABLE
(certificate Of Compliance
THIS IS TO CERTIFY, That the individual Well Constructed ( "f, Altered ( ), or Repaired ( )
by---------- e,ti"r //- ---------------------------
installer //
to
--------------------------------------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the appli a'tion•for Well Construction Permit No!f�'- p- � M ��Dated ---- - ZAP
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ---- -- Inspector-------------------------------------------------------------------------
�.,�.a..r.:s�:a:r.�.rns�.e4uti...._....-.-_.- .er.....wrw 9w[�F.�a+af-.+,rrr.+.ww .wsu. e.awr.e�!+r.-lwa.;.e!cb..e.a�►Vn� .irb+e+i+.4��^!��uwr:..4sYw� ri�++.dd�Y + p'.a�.ci.+�Airaa'a.an�r ac�� �C.+�au�..nyi
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ivell Congtruct ion Permit
No. Fee------------------
Permission is hereby granted -------
to Construct (t'f, Alter ( ), gr Re air ( ) an Individual Well at:
s= « / /
No. -��_-- ! �o _�S v— p----------------------------------------------------------------------------
street
t as'aho --on/t a application for Well Construction Permit
No. �' Dated---1__-_ -- - - -- -----------------------
Board of Health °
DATE--—/— —--__— — ------------
�D uS
r
MAP q,3 ��-
9 —/673 c
2- �' Flcs�
No.......... ...... �..............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
gh_---...---�Dt�U..4.........OF.........4A..11,M1�7N5 ...............................
'MY'
un for Daupuiial urkis - ii rttun runfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
(v4A... �U ............................ r.......�.......--•---•---------.....-•----
ocation- ddress or I of No.
�. .../ �� ........................
�6w /'ter Address
W
Type
Installer Address ,
T e of BuildingSize Lot...... .. ... .. ....Ser.4eet
Dwelling—No. of Bedrooms.... .__.-------_-•---_---.Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ... No. of persons............................ Showers — Cafeteria
Q' Other fixtures .___ _____
------------------------------------------------------------------------------------------•----•.....L• ---- ------------------
W Design Flow.....................�6... gallons per person per day. Total daily flow............... __._._..._ .__......gallons.
WSeptic Tank—Liquid capacity ll..gallons Length________________ Width........_._..___ Diameter__.__._________. Depth----------------
x Disposal Trench—No.-------I.........._ Width_.--/�._...... Total Length........VP...... Total leaching area......-._L2..sq. ft.
Seepage Pit No------------------- iameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (" ) Dosing tank ( ) p
'-' Percolation Test Results Performed by �j I Z..__.Y..4g:./ .................. Date...... ...�a-•.......
aTest Pit No. 1.....:?�------minutes per inch Depth of Test Pit--------4?...... Depth to ground water--__--7:_ '.._.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+' •--••-•-••---------------•--------•-......................... ....................................................................
O Description of Soil........................0.-1 ...... VX.0/�..:--:�ANAV .
x
. -• -J-B-S„ .l....................................................
c.> P----/-0---------{';E rJ------tVl: � ------ �--
W •-•-•••-•-••-------•--------------------•-------------......------ ------------------.........--•------------- -
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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Co �aseenued b t board of health.
i Signed .--- ---- .... . .. .....................
.....7 � �
Application Approved By ................... - -�, ----- --..................^
------ ------ ---------'---...—.'----------...---...................................... --'------
Date r
Application Disapproved for the following reasons: ................................................................. .................................................................
Permit No. � f �� Date
....................... Issued .. ....-... ........................
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
MLIA
�c
DA
TA
�
� 11
No................-.....-- `t' s Flcs..........................._
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
T .....`.. ..OF..........L....t.:... e�_'•-
Alip iration for Uiipoii al Works
Towitrn.rtion ramit
Application is hereby made for a Permit to Construct ( ") or Repair ( ) an Individual Sewage Disposal
System at:
.......... —.........- .. ' r ' I '_!:.: :- _,TT�F..! tFc! ...---•--------•-•---•---••-• j:�;---------------------------------------------------
} , Location-Address or Lot No.
Address
W
Installer Address —
Type of Building /� Size Lot--- .......
U Dwelling—No. of Bedrooms................................. .....Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria (. )
al Other fixtures -.;;---------------------•-------
W Design Flow.....................` .. _ _ ........ per person per day. Total daily flow................. _ .......gallons.
WSeptic Tank—Liquid capacity.........gallons Length---------------- Width................ Diameter---------------- Depth................
x Disposal Trench—No.-------0......._--- Width..... ,_....... Total Length........5.v...... Total leaching area..... ft.
Seepage Pit No.___•__--._.-._. ----.Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-' Percolation Test Results Performed
a
by F ` .................................o ' Date..... k_. --•---•---
04 Test Pit No. 1................minutes per inch Depth of Test Pit--------- Depth to ground water......._!._......
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�+ ---•------------------------------••-----------------------•---•----------------•---•-••.._.......--.........................................................
Description of
V Soil - .+ ...�
.v.[- : y -r r Si/�. cJIL -.-- •. ---
_ = --------------•----------------------•-•--•-------
........... ....................................................
---------------------
•------
-•-----------
.................•--------•-• .- ------•---• . . .. ... .. .. a....
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 TITLE 5 of the State Environmental 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 --------------------------------------------------------------------- --- - ---------------------------- ------------ ------------
Date
ApplicationApproved By ---- ------------------------------------------------------- ---------------------------------------------------- ----------------------- ----------------------------------------
Date
Application Disapproved for the following reasons: ------ ------------------------------------------------------------ ------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------------------------...................................................... ------ - ------------------------
Date
PermitNo. ----------------------------- ------------------------------- - Issued ----------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
--------------------I f1110J..... OF ..... 5. Llr
Te>r#ifi a e of C�umpXianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by ------------- --------------------- -------------------------------------------------- ------------------------.....-...............---------------------------------------------------------------------------.---------------
' ---�------------ - Installer
at ....----- - ----- .......P �..........- -........................................................----------------------------- ---------------------------------------------------------
has been install d in accor anc with the provisions of TITLE 5 of The State Environmental Cale as described in
the application for Disposal Works Construction Permit No. ....I:T-_f67r. ............ dated ....e... G..p ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE-----------------Z I` e s 1 7 .
Inspector C � - ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................. . . . .....................................
No......................... FEE........................
Bitiposal Works Tuonstrurtion prrutit
Permissionis hereby granted..............................................................................................................................................
to Construct ( A) or Repair ( ) an Individual Sewage Disposal System
atNo...............................................................................................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated..........................................
-----------------•--•--•.....---•-•--•-------•---------------------------.............................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
a5 �E FAm wi 4- Qt�Iz�c vA �E PL A� oN BAwC. fd�'
M0 6A¢13A6-c 6¢IL VW- 'DRIVE - Lma
'PAIL Fww = -4---A Ito =,fdo IPF LOT '�Y Ct+MP Doi
-swne- TANL ` aO X Roo _--
uS& 1500 GAL. q: *Z' 4
1�11G1}lf;!(s 5`{�T�JVI VES Fl� ,a " Tc
LEA.-* F'iB� t'L'xCiO fI4 TnA� _ -d. - TA�V-
d40 GPD 4 a`t SF= 5q s SF L. or-,
-blSYost�L Fi ELD
AppU"ToN AM �5t61J
'5lt4---wau. AWA* o .
13oTToAl A=A = 12 x5o =&W 6 F �
,MAL AjrA. (cosh' a _
3'teAsTMJE.
WED
OF
PETER --now TfleDL
VEHM SULLIVAN
NO.29733
No •ei CIVIL
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PMER'
29733
. sacm
CIVIL , f
w►way . , . .
M.'+.+. ... .-i..-.�.� � — .. ._1.«_.. ...+. .«....mow_+ +..r.=.-.1_ .._t . _ _. 1 -.__.... ..,_...rr+ , �. . V, .. �#-.A.. .• _.. ..+ s as a._ ,
TOWN OF BARNSTABLE
LOCATION' L L: tLe SIAneI 'Dfz. SEWAGE# nIL11D73
a SS_poS
i PILLAGE h`�'t t+•u,ILL ASSESSOR'S MAP&:LOT '
<'> ?INSTALLER'S NAME 8c PHONE NO. a s y 2�j ASS
:$EPTLC TANK CAPACITY 1 Sobs.
<LEACHING FACILrTY: (type) b -L t�� alcA (size) IZ.'7C 5b'. .
NO.OF BEDROOMS :
BUILDER OR OWNER
::':<;;,PERMITDATE: COMPLIANCE DATE:
:;:Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
• •. to S o23
• 1 Z I �I
2f, 3c,
S 74
3 ?7 .33
n ' r
ASSESSORS NIAF N `
No.-�=. _��f7_ NO
PARCEL
., -
BOARD OF HEALTH
TOWN OF BARNBTABLE
Applicat ion-*r Vell Congtruct ion Permit
Application is hereby made for a permit to �onstruct ( "), Alter ( ), or Repair ( )an individual Well at:
---------------- ------------------------------------------------------------------------------------
Location — Address Assessors rap and Parcel
brace �' ��7��iut 1<C _ �-4-1-
--------------------------- --------------------------------------------- - --------------------------------------- ----------------------------------------
Owner Address
- c 9 6 a ".�,a3� 9--`---- 1`�-----°c�----------------------- ----------- -- ---
Installer — Driller Address
Type of Building
Dwelling-----------------------------------------------------------------
Other - Type of Building----------------------------------- No. of Persons-----------------------------------------------------
r, — ------
Type of Well�---�� C-------------------------------------- Capacity------------------------------------------
--------------
Purpose of Well K--------------------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate .of Com Hance has been issued by the Board of Health.
Signed ---------------------------- r^
,�/' date
Application Approved By �h�c/
' date
Application Disapproved for the following reasons:--------------------- -----------------------------------------------------------------------
-- — -- ------ —�_--- ---------------------------------------------------------------------------------------------------------
z� date
__ � Issued — - -- T� � �
Permit No. --- ----------------- -----
-- ---------------------------- -----------------------
date
BOARD OF HEALTH
TOWN OF BARNBTABLE
(Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( 'I, Altered ( ), or Repaired( )
- --------- ----------------------------------------------------------------------------
-------------------------------
Installer
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection �•
Regulation as described in the application for Well Construction Permit No ated--
- -
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE- ---- ---— --- — -— -------- Inspector----------------------------------------—--- --—--------
M,
;Fee-- - - ---. ..
BOARD OF HEALTH
i
TOWN OF BARNSTABLE
Applicat ion for lVe[i Con5truc-to.n-Permit
Application is hereby made for a permit to onstruct ( I ), Alter ( ), or Repair ( )an individual Well at:
- ----------------------------------------------------------------------------------
Location — Address Assessors ap and Parcel
- --- y --------------------— --------- "- -----------------------
Owner Address
r_�-_' C N _1-1 1✓ �1- � �/ ----- --- - --- �ax------------------M u t - ---------�`'4-�----o J G--Y-?
.c
Installer Driller Address
Type of Building
Dwelling-------—-----—--------------------------------------------------
Other - Type of Building-------------------------------- No. of Persons--------------------------------------------------
Type of Well 1-'1_�J L----------- ----------- Capacity - -----------------
Purpose of Well--l1�,_c�_� ,v-^----q -�---------------------
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate .of Compliance has been issued by the Board of Health.
s
Signed ' --
• date
Application Approved By
I, date
Application Disapproved for the following reasons:-----—------- ----- ------—---------------------------—-------------------------------
:.=- ----------- ------------------
date
�
Permit No. --- � Z ----- Issued-----------------X-----------------4 ---------�-----------------
date
a -
"4 BOARD OF HEALTH
r�-.TOWN OF BARNSTABLE
C ertif irate m0f Compliance
THIS IS /T��OCERTIFY, That/the Individual j!V 1 Constructed ( 'I, Altered ( ), or Repaired
J/ A SLa N/U C' /( e �/ /✓fir. /
Installer
at1�—-----------------------------------------------------------------------------------------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health PrivateWell Protection
Regulation as described in the application for Well Construction Permit No -- � ---"-_ ated-- ----- ' ----`
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE- --- —- —-- ------- - ------------ Inspector---------------------------------------------------------------------------
BOARD OF HEALTH W
TOWN OF BARNSTABLE
VrIl Con0ruct ion Permit
No. �`�°-____------- Fee----- ---`-`----- --
Permission is hereby granted io —---- - -- — - - - -- -- —
to Construct (✓f, Alter ( ), or Repair ( ) an Individual Well at:
Gon.
G
No. - — -- - - — ----/' --— tree - - - - - -
f — ----�----- street
I as shown on the application for a Well Construction Permit
No.-A/— ' - - -----------------— - Dated---
---------- =" _ -
Board of Health ems .
DATE AP—
v - -
ENVIROTECH LABORATORIES, INC.
MA Cert. No.: M-MA 063
449 Rte. 130 . Sandwich, MA 02563
(508)888-6460 . 1-800-339-6460
FAX(508)888-6446
CLIENT: Bayside Building Co. LOCATION: Caddy Lamp Rd.
ADDRESS: Osterville, MA
SAMPLE DATE: 4-29-96
COLLECTED BY: DA Scannell DATE RECEIVED: 4-29-96
TIME: 10:30AM LAB I.D. #: E4-380
JOB TYPE: New Well SAMPLE I.D. #: E4-380
Irrigation
WELL SPECS.: 4" well
23,
RESULTS OF ANALYSIS:
Parameters Units Recommended Limit Result
Coliform bacteria/100ml (MF Method) 0 0
pH pH units 6.0-8.5 5.36
Conductance umhos/cm 500 110
Sodium mg/L 28.0 16.7
Nitrate-N/Nitrite-N mg/L 10.0 0.14
Iron mg/L 0.3 0.92
Manganese mg/L 0.05 0.096
COMMENTS: Low pH indicates high corrosive characteristics.
Iron and Manganese are not a health hazard, but can cause
taste, staining, and odor problems.
Yes WATER IS SUITABLE FOR DRINKING POSES R PARAMETERS TES
XXX
Date 6
Ron ld J. S ari
Laboratory Director
IT = Less Than
a
Assessor's Map : MAP: 93 PARCEL: 58-5 LOT: 5
Community Panel Number : 250001 0018 D
F.I.R.M. Map Zone: A13 (EL 11)
Plan Reference : Land Court Plan 41663 6 `l
Deed Reference — LC Cert.: 148,423 4• (PVC
SM.40(Trp) a•wN.- W sAx. oowl O E ALE
C �
Owner : William F. Markey, Jr., et ux. F TST H
Ref: SE 3 — 2930
3 4—1 11r WASHED STONE 1
2'PEAsE za• s T Marchh 17, 1988
roN
2O' 4c
;A' '►"
TOPSOIL
CROSS SECTION 'A—A' T SANDY SUBSOIL
NO SCALE
2'
COVERS LOCATED TO WITHIN "..".. - _ - - CLEAN
6'OF F.G.
MEDIUM
SAND
'. TOP OF - F.G.= 11.03 - ffi
FOUNDATION
i INV. 9.1 F.G.= 10.5•t -
INV. - 8.9
1500 GAL. IA FIRST 2'LEVEL `� :`•—7.4' OBSERVED WATER (EL = 2.0)
SEPTIC TANK INV. Bs INV. 8.4 DISL SCI�EOU
BO% 40 P.
INV. 8.2
10.00' .< 1_ INV. = 8.0 ' ' •.iY:« i .w•;.i a.�••:, •:.�;.
1 MIN. 6"CRUSHED •,•:'r."r ,.'r t?.ib'.';�:: '• i : ^•.
STONE BASE 1 ..y.{,^.•.:...� ..%!`••t .�'SS,,•:'�' -
Y BOTTOM ELEV. - 7.0
XDESIGN DATA
SINGLE FAMILY- 3 BEDROOMS
OBSERVED WATER LEVEL - EL. 2.0 p NO -GARBAGE GRINDER
PROFILE \ DAILY FLOV.' 1'0 X 3 = 330 G.P.D.
NO SCALE \ N/F BERKEY SEPTIC TANK.= 330 X 200% =660 G.P.D.
6 l USE 1500 GAL. SEPTIC TANK
Co LEACHING FIELD DESIGN
\ P ALL PIPES TO BE SCHEDULE 40 PVC PERFORATED
\ \ CB/DH FND USE 3 - 4" DISTRIBUTION LINES IN AN
\ Q 20'X 25' WASHED
ONE FIELD
S AS SHOWN
10 %k , / APPROXIMATE. LOCATION 330 G.P.D./.74 = 446 S.F. OF BOTTOM AREA REQUIRED
-- nF SEPTIC COMPONENTS USE 20'X 25 450 S.F. AREA PROVIDED
- --
gBA.v F PER SEWAGE PERMIT -- ___CLASj 1 SUi[ rtrtGOLATIGN-RATE I ?N 2 'A!N.--0R. ILrSc _
0,0
\. g5���
°��y < 29 LITTLE ISLAND DRIVE
o CB H FND o
•�� o �9 o�G� OSTERVILLE9 MASS.
# o \G 5� o /
PREPARED FOR
C LOT 5 N LCC�4.1663 �� BAYSIDE BUILDING CO■Y INC■
9Co. LOT 13 N LCC 9
�. Cuo �R? ,` PF!OPO
NEW
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2 • A 2 0 56,913 SF t �0 Septic System - Proposed Cottage
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z 16 . ® `� ; Baxter, Nye & ITolmgren, Inc.
/ 2?07'9• Registered Professional
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ev x I! 812 Mein Street, Osterville, Massachusetts 02655
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SCALE.1 = 40 DATE: 11-16-2000
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�� REV. DATE: REMARKS
U) I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE THE EXISTING
AND PROPOSED STRUCTURES SHOWN HERON ARE IN COMPLIANCE a'".— col
WITH THE APPLICABLE BARNSTABLE ZONING DISTRICT SIDELINE
AND SETBACK REQUIREMENTS, ARE LOCATED IN RELATION TO IOE ti
C_ THE MONUMENTS SHOWN, AND ARE LOCATED WITHIN THE SPECIAL L1 S 53'32'50" E 27.28'
FLOOD HAZARD AREA AS NOTED. % P_,s L2 S 58'57'50" E 34.86' DRAWING NUMBER
2'57
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H: 1995 95133_5 SURVEY WORKSHY 95133_5SEP.DWG
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In RE ISTERED ROFESSIONAL LAND SURVEYOR DATECn
95133_5
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