HomeMy WebLinkAbout0406 MAIN STREET (OST.) - Health 406 MAIN STf EE
OSTERVILLE
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Commonwealth of Massachusetts.
Title. 5 Official Inspection Form
Subsurface Sewage Disposal System Form . Not for Voluntary Assessments_.
406.Main. St. O. -
PropertyAddress ..
Ronald Gray_&Stephen,Mermelstein
:Owner
Owner's Name:: : . . .. . _. .. .
information is
required for every :Osterville t: Ma. 02655 5/24/13
page: . CityfTown _ State Zip Code Date of Inspection
. r
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 X-General Information,
.... :filling out forms ... . _. ....? -.... ,
'onthe computer,
use only the tab. -1. Inspector:, 0 �5
key.fo move your
cursor_do not
use:4he return
Ricky Wright
:..- .
key..'. Name cif Inspector. '
B & B Excavation;Inc:
reb Company Name 7 _
r.
14 Teaberr Lane :::
Company Address
Forestdale
ci
fv!Town MA .0
2644 44
,._. . . .. ": State..
508=477-0653 z Zip Code:: '
Telephone Number F S1.4595 '
License Numb '
',: h. er
t x.
z
ertification .' . . ,
P p y.. P g
(:certify that I have ersonall inspected the sewa e.disposal system at this address'and that the
-
Von re orted below Is'#rue,accurate and complete as of the 'time of the inspection. The s n pe 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:pursuantto Section 15,340 of
Title 5:(310 CMR 15.000). The system:
®_'Passes
y ❑ Conditionally Passes ❑ Falls
❑ Needs Further:Evaluation' by the:Local A pproving Authority
Y =Inspectors Signature 5/24/13
Date
The system inspector shall submit.a copy of this.inspection-report to the Approvin ^'Authori
of Health.or.DEP)within 30 days of completing this Inspection. if the systerri isya shared system
has a.design flow of 10;000:gpd or greater, the inspector and the s stem
9 ty(Board
report to:the a ro hate regional,office of the DER The.original should be se Y m or
pp p;
Y. owner-shall submit the +
copies sent to the bu er If a licable; and the a
and Y pp
sent to the system owner
pproving authority.
This`report:only describes conditions at�the time of inspection and under the- M
at that time.-This inspection does not address how the system will perform.in the fut
e conditions of use .
the same:or different conditions of use. ure under
t5ins r 11/10
�3
Title 5 Official Inspection Form:SUbSUrfaGe 56WSgS�tg�byai� 1em Page-1.of 17 r"
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
^M 406 Mainn St.
Property Address
Ronald Gray&Stephen Mermelstein
Owner Owner's Name
information is required for every Osterville Ma. 02655 5/24/13
page. Citilfown 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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in.310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:,
B) System Conditionally Passes:
E 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
insound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
nspection if the existing tank is replaced with a complying septic tank as approved by the Board of
:iealth.
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 0 N El ND (Explain below):
t5ins-11/10 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 406 Mainn St.
Property Address
Ronald Gray&Stephen Mermelstein
Owner Owner's Name
information is ill t O_` erye Ma. 02655 5/24/13
required for 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 Ievel,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):
• y
C) Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board'of Healthi in order to'determine,if
the system is failing to protect public health, safety or the environment. h
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 f
t5ins,•11/10 Title 5 Official Inspection Form:Subsurface Sewage Dis?osal System•Page 3 of 17
Commonwealth of Massachusetts
w Title 5 Official 'inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
°M 406 Mainn St.
Property Address
Ronald Gray&Stephen Mermelstein'
Owner Owner's Name
information is required for every Osterville mi. 02655 5/24/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and.environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface.water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
•
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or,"No" to each of the following for all,inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
3 ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
k due to an overloaded or clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded
El ® or clogged SAS or cesspool
Liquid depth in cesspool is less than 6 below Invert or available volume is less
El ® than 1h day flow
t5ins•11/10, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 406 Mainn St.
M
Property Address
Ronald Gray&Stephen Mermelstein ,
Owner Owner's Name
information is required for every Osterville Ma. 02655 5/24/13
page. City,?own 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.
El ® 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 azesspool 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,
4 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 i
El El 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
F Areas — IWPA)or a mapped Zone li of a public water supply well;..
If you have answered "yes" to.any question in Section E the system is considered a•significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
,,system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System r Page of 17
Commonwealth of Massachusetts .. .. -
Tit[e 50 Inspection Form -
Subsurface Sewage Disposal System Form . Not for Voluntary Assessments
406 Mainn St:
Property Address: a u,
Ronald Gray&Stephen Mermelstein
Owner: Owner's Name
information is
required for every:. Ostarville Ma. 02655 5/24/13
page:.. Crtyrrown;:. ...... State Zip Code,:::: Date of]nspectioh; ......
.. 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:
❑ Z 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 arid:examined?(If they were not.:: :.
❑ ® available note as N/A)
® ❑ Was the.facility or dwelling inspected for.signs of sewage back up?
.... ... ... .... .... r-. ::.:�
® . El as the site inspected for signs of break out?
® ❑ were all system components, excluding the SAS, located on site?. . F
:.::. ..... _ ..
Z ❑ 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 ovine&(and occupants if'differentfrom.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
Det
ermined in the field(if an of the allure criteria related to Pa I u y f c i Part C is issue
T, ❑ approximation of distance is unacce table)[310 CMR 15.302(5)]
D. S stem Information
Y,_
Residential.Flow Conditions: ;
3 3
Number.of bedrooms(design): Number.of bedrooms(actual);
...... ..... }. r .i; r .. .. .. .-. .l .. ....
DESIGN flow based.on 310 CMR 15.203,(for example: 110 gpd x#of bedrooms): ._ 330
t5ins•11/10;:; Title 5 Official Inspection Form:Subsurface Sewage Disposal System;•:Page 6 of 17:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Vol u ntary'Assessm ents
°M 406 Mainn St.
Property Address
Ronald Gray &Stephen Mermelstein
Owner Owner's Name
information is required for every Osterville Ma. 02655 5/24/13
page. City/Town 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
Seasonal use.?. - ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): n/a
Detail:
Sump pump? ❑ Yes '® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gauons 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments
�M 406 Mai'nn St.
Property Address
Ronald Gray&Stephen Mermelstein
Owner Owne,-'s Name
information is required for every Osterville Ma. . 02655 5/24/13
page. CityM)wn State Zip Code• Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date _
Other(describe below):
General Information
Pumping Records:
x -
Source of information:
r
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
Y inspection of the I/A,system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
El Other(describe):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
G7M 406 Mainn St.
Property Address
Ronald Gray&Stephen Mermelstein
Owner Owner's Name
information is required for every Osterville Ma. 02655 5/24/13
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:
3/14/01
Were sewage odors detected when arriving of the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18"
feet ,
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):,-
,
>20
Distance from private water supply well or suction line- feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be"in working order no sign of leakage or blockage.
Septic Tank(locate on site plan):
Depth bellow 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
Cimensions: 1500 gal
6"
Sludge depth: _
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 406 Mainn St.
Property Address
Ronald Gray&Stephen Mermelstein 4
Owner Owner's Name
information is required for every Osterville Ma. 02655 5/24/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
2811 '
Distance from top of sludge to bottom of outlet.tee or baffle
Scum thickness no scum
Distance from top of scum to top of outlet tee or baffle no scum
Distance from bottom of scum to bottom of outlet tee or baffle no scum
How were dimensions determined? scour stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appears to be structurally sound. No sign of back-up.
Grease Trap`(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: t
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
t.
Date of last pumping:
Date
t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage'Disposal System-Page 10 of 17
w
Commonwealth of Massachusetts,
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 4061Mainn St.
Property Address
Ronald Gray&Stephen Mermelstein
Owner Owner's Name
information is required for every Osterville Ma. 02655 5/24/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.) F
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):.,
h ight 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
,f ..
Comments (condition of alarm and float switches, etc.):
s *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑, No `
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
406 Mainn St.
Property Address a
Ronald Gray&Stephen Mermelstein
Owner Owner's Name
information is required for every Osteryille Ma. 02655 5/24/1,3
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 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.):
At time of inspection d-box appears to be in working condition.No sign of carryover or leakage.
Pump Chamber(locate on site plan):
Pumps in working order: El Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition,of pumps and appurtenances, etc.):
j
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why: -
t5ins•11/10 ¢ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
WTitle 5 Official Inspection Form
Subsurface Sewage-Disposal System Form- Not for Voluntary Assessments
° M 406 Mainn St.
Property Address
Ronald Gray&Stephen Mermelstein
Owner Owner's Name
information is required for every Osterville Ma• 02655 5/24/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2-500 gal.
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.):
At time of inspection leaching appears to be in working condition. No sign of hydraulic failure.Water
level 18" below invert 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
r Depth of solids layer .
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
406 Mainn St.
Property Address
b
Ronald Gray&Stephen Mermelstein
Owner Owner's Name
information is required for every Osterville Ma. 02655 5/24/13
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.):
R
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of)7 .
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments.
�M 406 Mainn St.
s
Property Address
Ronald Gray&Stephen Mermelstein
Owner Owner's Name
information is
required for every Ostervillle Ma. 02655 5/24/13
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
0 drawing attached separately
r - ,
;+ s
A3 , q3
t5ins•11/10 a Title 5 Official Inspection Form:Subsurface Sewage"Disposal.System•Page 15 of 17
I
Commonwealth of Massachusetts" s
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 406 Mainn St.
Property Address -
Ronald Gray&Stephen Mermelstein .,
Owner Owner's Name
information is required for every Osterville Ma. 02655 5/24/13
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.) ,
R .
Site Exam:
® Check Slope
® Surface water r
® Check cellar
® Shallow wells
Estimated depth to high ground water: >12
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 7/18/2000
Date r
❑ 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:
i
Before filing this Inspection Report, please see Report Completeness Checklist on next page. .
6
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System'-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
406 Mainn St.
Property Address
Ronald Gray&Stephen Mermelstein .
Owner Owner's Name
information is ,
required for every Osterville Ma. 02655 5/24/13
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 t
Z Sketch of Sewage Disposal System either drawn on page 1`5 or attached in separate file
x
r
Y
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
MAY, 2 9 2001
TITLE 5 TOWN ur BAKNJ I ABLE
HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTAR
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 4 0 H Main St
Ostervillp
Owner's Name:
Owner's Address:
Date of Inspection: ZV --P)
Name of Inspector: (please print) Wi 1 1 i am E. . Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (5 0 8) 7 7 5—8 7 7 6
CERTIFICATION STATEMENT
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 7astses
Sect' n 15.340 of Title 5(310 CMR 15.000). The system:
Conditionally Passes "
Needs Further Evaluation by the Local Approving Authority
v Fails
Inspector's Signature: V� �/� Date: 3::U-
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatthw
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
****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 1
Page 2 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART
CERTIFICATION(continued)
Property Address: 4 0 6 Main S t_
Oster`ville
Owner.' .' Estate of Sheckelton
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys m 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. ystem Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repair .The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answe yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain
e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsoun ,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existin tank is replaced with a complying septic tank as approved by the Board of Health.
•A me I septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indica ' g that the tank is less than 20 years old is available.
ND xplain:
Observation of sewage backup or break out or high static water level in the distribution box due to-broken or
ob trusted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
ap roval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND xplain:
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 exp ain:
Page 3 of l 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
.SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 406 Main St.
Osterville
Owner: Estate of Sheckelton
Date of Inspection: 3—/-/—® 1 a�
Clfafling
urther 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 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
ystem 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. ystem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
syst m 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
ivate water supply well**. Method used to determine distance
*This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
acteria and volatile organic compounds indicates that the well is free from pollution from that facility and
e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
ailure criteria are triggered.A copy of the analysis must be attached to this form.
3. ther:
3
Page 4 of 11 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 406 Main St.
Csterwjl le--
Owner: 1.S heekelton
Date of Inspection: {;� —O
System Failure Criteria applicable to all systems:.
u must indicate`yes"or"no"to each of the following for all inspections:
Ye No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
_ 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 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.]
(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 a considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gP
Yo must indicate either"yes"or"no"to each of the following:
( e following criteria apply to large systems in addition to the criteria above)
s 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 yo have answered"yes"to any question in Section E the system is cmidered a significant threat,or answered
"yes" Section D above the large system has failed.The owner or operator of any large system considered a
signi cant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.30 .The system owner should contact the appropriate regional office of the Department.
4
y
Page 5 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 406 Main St
OstervillP
Owner: Estate of S_lhe,ckelton
Date of Inspection: 3-Y9--12 l
Check if the following have been done You must indicate"yes"or"no"as to each of the following:
Yes No/
�9_// 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?
V — Has the system received normal flows in the previous two week period?
,I/ Have large volumes of water been introduced to the system recently or as part of this inspection?
_ V Were as built plans of the system obtained and examined?(If they were not available note as N/A)
a back up?J
inspected for signs of sewage/ Was the facility or dwelling p g g
_- Was the site inspected for signs of break out?"
t/ Were all system components,excluding the SAS,located on site
. G/Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
o_f 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:
Yes no
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(3)(b)]
5
}
i
Page 6 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address. 406 Main St.
Osterville
Owner: Estate of ,�,!heckelton
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):y Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 1I 4I 6
Number of current residents: P-,
Does residence have a garbage grinder(yes or no):/L.o
Is laundry on a separate sewage system(yes or no):k.C� [if yes separate inspection required]
Laundry system inspected(yes or no):AD
Seasonal use: (yes or no):/L O
Water meter readings,if available(last 2 years usage(gpd)): 2000 125,000 gal.
Sump pump(yes or no):&0 1999 24, 000 gal.
Last date of occupancy: p I
C MMERCIAL/INDUSTRIAL
T e of establishment:
Des n flow(based on 310 CMR 15.203): gpd
Basi of design flow(seats/persons/sqft,etc.):
Gre a trap present(yes or no):
Indu trial waste holding tank present(yes or no):_
Non anitary waste discharged to the Title 5 system(yes or no):_
Wat r meter readings,if available:
Las date of occupancy/use:
O ER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): d
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TOF SYSTEM
YP2 OF
distribution box soil absorption_ P system
_Single cesspool
Overflow cesspool
—ivy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of info tion:
Were sewage odors detected when arriving at the site(yes or no): O
6
,Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 406 Main St -
ORtPrvi11P
Owner: FGtate of Sheckelton
Date of Inspection:
B ^ LDING SEWER(locate on site plan)
Dep below grade:
Mate ials of construction:_cast iron _40 PVC_other(explain):
Dista ce frcm private water supply well or suction line:
Co ents(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ' (locate on site plan)
Depth below grade: /
Material of construction:_concrete_metal_ berglass polyethylene
_other(exolain) D
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) ,
Dimensions: b Cy }
Sludge depth: 8 ,
Distance from top of sludge to bottom of outlet tee or baffle: 2�
Scum thickness: 0
Distance from top of scum to top of outlet tee or baffle: $- ,
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
tiLy leJ I& o-6 l� 0 G A`p c Gd ` S
G ASE TRAP:_(locate on site plan)
Depth below grade:
Materi 1 of construction:_concrete_metal_fiberglass polyethylene_other
(expla' ):
Dimen 'ons:
Scum t ickn2ss:
Distan a from top of scum to top of outlet tee or baffle:
Distan a from bottom of scum to bottom of outlet tee or baffle:
Date o last pumping:
Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as re ted to outlet invert,evidence of leakage,etc.):
t 7
Page 8 of l 1 .
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 406 Main St.
nSt-Prvi 1 1 2
Owner: Ff Sheckelton
Date of Inspection: —b
T HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Dep below grade:
Mate ial of construction: concrete metal fiberglass polyethylene other(explain):
Dime sions:
Capac ty: gallons
Desig Flow: gallons/day
Al present(yes or no):
Al level: Alarm in working order(yes or no):
Date f last pumping:
Co ents(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: P
resent must be(L if o ened)(locate on site plan) .
P
Depth of liquid level above outlet invert: 6
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.):
PU P CHAMBER: (locate on site plan)
Pum s in working order(yes or no):
Al s in working order(yes or no):
Co ents(note condition of pump chamber,condition of pumps and appurtenances,etc.):
i
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: -4 0 h Main $f-
• OGtarvi 1 1 a -
Owner: FGtatp of Sheckelton
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): c/(locate on site plan,excavation not required)
If SAS not located explain why:
Type
teaching pits,number:
leaching chambers,number: �-
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
0 'F c a s t T G Lr> ,7'� �/ f S I o �v i� A it aun,
CESSPOOLS: (cesspool must be pumpe as part of inspection)(locate on site plan)
Number and configuration: �4-
Depth—top of liquid to inlet in e
Depth of solids layer:
Depth of scum layer: n
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.):
PR (locate on site plan) ,
Mat rials of construction:
Dim nsions:
Dep h of solids:
Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 406 Main St.
Osterville
Owner: Estate of Sheckelton
Date of Inspection: —/2— /
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.
I
1
13 b
s
-3
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 406 main gt
nCt PT"V11•1 ,
Owner: e! of Sheckelton
Date of Inspection: 3
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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:
1/ bserved site(abutting property/observation hole within 150 feet of SAS)
hecked 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 round water elevation:
o b 'I
v
11
TOWN OF BARNSTABLE �'
LOCATION i22r, In 1,1- SEWAGE'#qU L�1.�
VILLAGE t D Y v'�1(9, ASSESSOR'S MAP& LOT Ik --D��
INSTALLER'S NAME&PHONE NO. 8OL 246L'0S&l —27.r Y 7-U
SEPTIC TANK CAPACITY f� ��!►�/
LEACHING FACILITY: (type) (size) �?5`
NO.OF.BEDROOMS
BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE:
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
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y' e 1 ••
i yap m�°� �.t
� e
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a
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�.��}
�;i of,
`� ,
y�;
f
y�' ® . _ t
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No. �' V Fee$5 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
application for Mie;pogaf *r5tem Construction Permit
Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
406 Main St . , Osterville Estate of Everett Sheckelton
Assessor's Map/Parcel
Attormey Peter Paull Jr.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
P 0 Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms— — Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil S and.
Nature of Repairs or Alterations(Answer when applicable) Title-5 c e pt i o t em Q Qns i s t ins
/ ? Y 7 L c/:Date last 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 issued by thi Boao o as
-AJ
Signed � G�-� Date
Application Approved by 4 Date 7 - I Q-60
Application Disapproved fort a fol ing reasons
Permit No. m-1,000 9' Date Issued
Fe
No. e�""� 1 e$5 0
.. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
4 ' PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS
�.u., ZIppftcation for r opoi zal 6pztem Construction Permit
Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) El Complete System ❑Individual Components
L catio Address or Lot No. Owner's Name,Address and Tel.No.
06 Main St. , Osterville Estate of Everett 'Sheckelton
Assessor'sMap/Parcel Attormey Peter Paull Jr.
Ins er's e,Him,and Tel.N Designer,Name,Address and Tel.No.
�n `: 1 0 inson teptic Service
P 0 Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms .3 Lot Size sq.ft. Garbage Grinder( )
r Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand.
Nature of Repairs or Alterations(Answer when applicable) Title-5 sent it ystem consisting
of a tank, D-box and. Xconcrete leach chambers with stone all around .
`,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=a
cate of Compliance has been issued by th'
Signed =- . 2��M - Date f
Application Approved by ! Date 7 -,
Application Disapproved for the follo ing reasons
Permit No. C;L000 Date Issued
——————— —————* ————— — ———————————————
THE COMMONWEALTH OF MASSACHUSETTS
elton BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO�ERTIF,Y,th O%e nson S e ZDcp er�rsic Constructed( )Repaired(X )Upgraded( )
Abandoned( )by Me E
at 406 Main St . , 0 s t e ry i l le has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.�-�'�- dated
Installer my. E. Robinson S r. Designer
The issuance of tlu's ggtt�Yhs�all not be construed as a guarantee that the sy t will tr�ct as design
Date Inspector.
---------------------------------------
No. dmo" 11O Fee $50
THE COMMONWEALTH OF MASSACHUSETTS
Sheckelton PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Oigpooal *pgteT Conotruction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( )
Systemlocatedat4'06 Main St. , Osterville
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 ermit.
Date: -7 i`r Approved by
441
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMTT(WITHOUT DESIGNED PLANS)
I, William E. Robinson,s�eby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at 4 0 6 Main St . , 0 s t e ry i l l a meets all of the
following criteria:
• The ' ed system is connected to a residential dwelling only. There are no commercial or business
Th 7Fated with the dwelling.
,1 ,s classified as CLASS I and the percolation rate is less than or equal to:5 minutes per inch.
are no wetlands within 100 feet of the proposed septic s�;stem
( There are no private wells within 150 feet of the proposed septic system
e is no increase in flow and/or change in use proposed
There are no variances requested or needed.
e bottom of the proposed leaching facility will nit be low less than five feet above the
mammtun adjusted groundwater table elevation: [Adjust the groundwater table using the Frimptor
method when applicable)
o 'if the S.A.S.will be located with 250 feet of any vegetated wetlands.the bottom of the proposed
leaching facility will Mt be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) 3S
B) G.W.Elevation _ +the MAX. High G.W. Adjustmentk= RO
DIFFERENCE BETWEEN A and B V g
SIGNED : Y Y ✓ DATE:
(Sketch proposed plan of system on back).
y:hmM folder:cat.
L
M
+MM
TOWN OF BARNSTABLE.
LOCATION L, `f, SEWAGE
vII.LAGE ASSESSOR'S MAP & LOT )(05 -0
INSTALLER'S-NAME&PHONE NO. _T_ 'j
SEPTIC TANK CAPACITY . yU
1 LEACHING FACILITY: n
(type) (size)
NO.OF BEDROOMS
BUII-DER OR OWNER. .
PERMITDATE: COMPLIANCE DATE:'%�,/- dT j
Separation Distance Between the:..
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Su PP Y 1 We11 and LeactiittgFacility,-(If any wells exist
`
on site or within 200 feet of leaching facility) Feet
i Edge-of Wetland and Leaching Facility (If any wetlands exist,.
within-30U feet of leaching.racility) / '. Feet
Furnished by
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0
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