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0421 MAIN STREET (OST.) UNIT #B - Health (2)
421 MAIN STRE9 T, ®STERVILLt, A=164.004 - I 0 Commonwealth of Massachusetts '019 Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 421 Main Street(Main House System) Property Address , Edward & Nancy Eskandarian Owner Owner's Name r` information is ' required for every Osterville Ma 02655 7/13/2019 + 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. Imngoutf rms A. Inspector Information �/„ / 39&filling out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. Co pang A Lane ,� Company Address Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com, SI4522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7/13/2019 Inspector's Signature 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 421 Main Street(Main House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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 property located at 421 Main St Osterville( main house) is served by a Title V septic system consisting of a 3000 gallon 2 compartment septic tank, distribution box and a leach field with 20 Cultec Rechargers. The system was found to be in proper working condition at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Lt5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 421 Main Street(Main House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR r 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,u 421 Main Street(Main House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is Osterville Ma 02655 7/13/2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. . ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *`This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Main House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) . System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Main House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not _ available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Ala Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 421 Main Street(Main House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 9 Number of bedrooms (actual): 9 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1980 gpd provided Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 421 Main.Street(Main House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cty/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes Z No If yes, volume pumped: gallons How was quantity pumped determined? Reason for um in : p p 9 t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Main House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank; distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: system installed 4/20/1998 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 3 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 in good condition, no leakage, vented through roof. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Main House System) Property Address E Jward & Nancy Eskandarian Owner Owner's Name information is Osterville Ma 02655 7/13/2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2.5 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: 3000 gallon 2 compartment 5,i Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2'i 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 10" How were dimensions determined? Opened covers and took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. Water level was even with outlet, tank was not leaking and was structurally sound. Inlet and outlet covers are on risers. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Main House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Csterville Ma 02655 7/13/201'9 page. Cty/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Main House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date.of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Oil 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.): Distribution box was video inspected and found level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 421 Main Street(Main House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t Type: ❑ leaching pits number: ® leaching chambers number: 20 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 421 Main Street(Main House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is Osterville Ma 02655 7/13/2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. consists of 20 Cultec Rechargers. No signs of past overloading. No lush vegetation. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Mai; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Main House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 4 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 i Commonwealth of Massachusetts ie Title 5 Official Inspection Form <o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Main House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) i 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Ago, � 6 Al 23 P�2 36 G �2 53 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ` i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I � . ., 421 Main Street(Main House System) Property Address Edward & Nancy Eskandarian Owner Owners Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityf7own State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope ® Surface water cellar Check c ❑ Shallow wells Estimated depth to high ground water: 12'+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev-7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form 5 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 421 Main Street(Main House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist).completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 c Commonwealth of Massachusetts 11ey' v D l Title 5 Official Inspection Form <I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Guest House System) Property Address Edward & Nancy Eskandarian Owner Owner's NamQ ra, information is required for every osteryille �/ Ma 02655 7/13/2019 r page. Cityrrown State Zip Code Date of Inspection r 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 A. Inspector Information BSI / filling out forms �f l 9/ on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane rQ Company Address Centerville Ma 02632 Cityrrown State Zip Code few 774-248-4850 smjonestitle5@gmail.com, S14522 lean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails , i 7/13/2019 Inspector's Signature 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v 421 Main Street(Guest House System) Property Address Edward & Nancy Eskandarian Owner . Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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 property located at 421 Main St Osterville( guest house) is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 4 leaching chambers. The system was found to be in proper working condition at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Guest House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Guest House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No 0 ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 In Official spection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Guest House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection C, Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply.well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ® The system fails. I have determined that one.or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400.feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim,Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 421 Main Street(Guest House System) Property Address Edward & Nancy Eskandarian Owner Owners Name information is required for every Osterville Ma 02655 1/13/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes iNo ® ❑ 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? k ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �o 421 Main Street(Guest House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 461 gpd provided Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date t5insp.doc•rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Guest House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form �' as Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 421 Main Street(Guest House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 'Approximate age of all components, date installed (if known) and source of information: system installed 3/18/2009 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2 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 in good condition, no leakage, vented through roof. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts i� Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Guest House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityi Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5 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 1500 gallon Dimensions. 2" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 4' Scum thickness Oil 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 10" How were dimensions determined? Opened covers and took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. Water level was even with outlet, tank was not leaking and was structurally sound. Inlet and outlet covers are on risers with steel covers. t t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form 1' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 421 Main Street(Guest House System) P'-operty Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every C°sterville Ma 02655 7/13/2019 page. C,,ty/Town State Zip Code Date of Inspection D. System Information (cont.) 7 Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain): e Dimensions: ' I I� Capacity: gallons i Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1' o� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 421 Main Street(Guest House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? _ ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was found level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. Cover is on riser with steel cover Lt5 insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <�a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 421 Main Street(Guest House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Guest House System) Property Address Edward & Nancy Eskandarian Owner Owners Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching facility was found dry with a clean sandy bottom. Cover is on riser with steel cover. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Guest House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions 9„ Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 1 , r I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 42'1 Main Street(Guest House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately O ALL Cove�S Dc" sfie�c. C�v�� t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Guest House System) (Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Guest House System) Property Address Edward & Nancy Eskandarian Owner Owners Name information is required for every Cisterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - r 421 Main Street(Pool House System) r Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection n 9a5 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 A. Inspector Information v'l# /89v�5 filling out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Company A Lane Co � Company Address Centerville Ma 02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com, S14522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7/13/2019 Inspector's Signature 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <lo Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4.21 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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 property located at 421 Main St Osterville ( pool house) is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and a leach field with 3 Cultec chambers. The system was found to be in proper working condition at the time of inspection. 2), System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form to Subsurface Sewage Disposal System Form Not for Voluntary Assessments 6 421 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is Osterville Ma 02655 7/13/2019 required for every � page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) F ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: '' **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: E.' �i 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: z Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 421 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owners Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary(cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 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 water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion. of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—iWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 421 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6: You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS),on the site has been determined based on: ® ❑ Existing information.For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection D. System Information 1, Residential Flow Conditions: Number of bedrooms (design): -3 Number of bedrooms(actual): 0 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Description: Pool house with no bedrooms 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑. Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 I f Commonwealth of Massachusetts Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 421 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type.of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy - ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑' Tight tank. Attach a copy of the DEP approval. ❑' Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ .Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1.5feet 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 in good condition, no leakage, vented through roof. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 421 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 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" Distance from top of sludge to bottom of outlet tee or baffle 4' 0il Scum thickness 711 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. Water level was even with outlet, tank was not leaking and was structurally sound. t5insp.doc-rev.7/26/2018 A Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts 'Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) '. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date ._ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: I ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. CityiTown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was video inspected and found level and in good condition with no rot. Water level_ was even with outlet invert with no signs of past backup. t5insp.doc•rev.712 612 01 8, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® ultec leaching chambers number: 3 Chambers ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form fP �a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4� 421 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. consists of 3 Cultec Rechargers. No signs of past overloading. No lush vegetation. I 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 f Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 421 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13: Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts 'Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 421 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately _f Z3 , `' (33 AY Z5 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 421 Main Street(Pool House System) Property Address Edward & Nancy Eskandarian Owner Owner's Name information is required for every Osterville Ma 02655 7/13/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector information: Complete all fields in this section. ® B. Certification_ Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev,7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNS_TABLE LOCATION SEWAGE# �` VILLAGE �� f i ASSESSOR'S MAP&PAR EL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY_ %f, � LEACHING FACILITY:(type) p (size) NO.OF BEDROOMS t OWNER Gl/. PERMIT DATE: COMPLIANCE DATE: �► d i Separation Distance/Bet;/en 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 g --�� � A 3--. t No. a (� Fee 1 THE COMMONWEALTH OF.MASSACHUSETTS Entered in computer: 0�1 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS . Ye Iapplication for ]Disposal Opstem Construction J)ermit Application for a Permit to Construct(--4--Repair( ) Upgrade( ) Abandon( ) complete System ❑Individual Components. Location Address or Lot No. 446 MA.1k) Sf Owner's Name,Address and Tel.No. 05TC�t�Le EMRRp-*A)"CllC �c a Assessor'sMap/Parcel I taller's N e,Address, d:Tel.NoJ., Designer's Nine d Fe,and Tel.No. C/r l i C/�✓ u we ENb ij4t� �N` �-�� �O I95—-615� ��ti w�a Sb�-`t2i!33q� Type of Building: (�RfJkco.� Dwelling No.of Bedrooms Lot Size 5.4 q &ce c-S Garbage Grinder(AQ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures a Design Flow(min.required) a gpd Design flow provided y(l[ gpd Plan Date MR ( (11,zdo`j Number of sheets Revision Date Title Stiff'-PLftvJ 7 PQ���Iu MC Size of Septic Tank (5TC1a 6PrL(d,0 Type of S.A.S. Description of'Soil 0-S' (U'dk9 ML) 'FtLL o&- C1 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 nq o place the system in operation until a Certificate of Compliance has been issued by this Board of eal G ign d 9Y- z2, Date Ap'"cation Approved by / Date A lication Disapproved by Date fo he following reasons Permit No. Date Issued ", .cn:..n..--w+•.,.r -<r-.,+�rr^"'.a'TMf'..� r:+x..ra•.-,..q.�..,-..f..._,�Ss..in+'r.X+.+.+F .••Y -.r.�,�+�r.r.m'+,....•!.•-.++. .- �.J .,. r-4,ro:.. .. T.,.\. .f„- ...,,1-., .. .... - - -- •�•---�.`ti,.-.-.,.•"i;,t^. . �.r''�No. ( "• Fee `J THE COMM Entered in computer: t / t COMMONWEALTH OF, ; Yes PUBLIC-HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETnTS ' ; y ftpffcatiou for Vsposaf *pstent Construction permit Application for a Permit to Construct PP ( ) Repair( ) Upgrade( Abandon( ) ©°Complete System ❑Individual Components Location Address or Lot No. tiZ) M#N1�ST- Owner's Name,Address,and Tel.No. OSTt64jI,-LC LMNA\D-7 AJ+#acy Assessor'sMap/Parcel (C -wL- 1564% ~ILS"- Sr 080(0 u�storu o2_I(c `s Installer's N me,Address,and Tel.No Designer's Name Address and Tel.No. tti-v+1 d.s 5)cL,v EAt tktt4_016, T,&)s �?u.fox rosy !!It' Z�1u► 6 '`�' lT ' c�lC04ak�,_c %n� Type of Building: Dwelling No.of Bedrooms L' Lot Size 5.4 k4 pe e eS --sq-fl: Garbage Grinder(Nv) Other Type of Building No.of Persons Showers( ) Cafeteria( ) a Other Fixtures Design Flow(min.required) gpd (Design flow provided y(e gpd Plan Date j}k(14 Il{e Uo 9 Number of sheets Revision Date Title 51TT t>C i1 MC kR ' -L Size of Septic Tank 1'700 (OkC(d tJ Type of S.A.S. — (116t gEk j !N A. IZ' x 36� FtCa_i:" 'r Description of Soil 31,( 17_488 l�—S '(�t �( �� N 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 Certificate of Compliance has been issued by thsBoazdyo�ffHealth: �� _, Signed /,// �i� --*�' f"!'7 _ /1 n it Date / Application Approved by ,� '� > �!��1 � / i(� �_ Date u /p Application Disapproved by / / r 1 ✓v Date formthe following reasons ` n Permit No. �/56 Date Issued ---------------- -----------� • - -- ------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS r Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage-Disposal system Constructed(/) Repaired( ) Upgraded( ) Abandoned( )byj /S at C{i Z( A A 1 N A"ar Qv 1 t L L- , has been constructed in accordance �y with the provisions of Title 5 and the for Disposal System Construction Permit No. � 1,94 P P Y �'���-'4��dated - Installer Designer #bedrooms Approved design flow. gpd The issuance of/th_ •s Permit shall not be construed as a guarantee that the system will - h n as designed. Date y��1�/o Inspector /�Q/ + _, Y t ' _ - No.- - e-- - - r - -- - - - --_- -- ----� _ -- ---- -- - -- - - - - -- THE COMMONWEALTH OF MASSACHUSETTS ` PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS E Misposal *pstem Construction 3permit Permission is hereby granted to Construct Repair( ) Upgrade( ) Abandon( ) System located at Ll L( Mal ti <N and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. i J ctio mG Provided:Constru �st b omed within three years of the date of this permit. ` AP, Date / Approved by p et Town of Barnstable- °FtHE ra,, Regulatory,Services Thomas F. Geiler, Director '" &% Public Health Division prfp3s61 Thomas McKean;Director 200 Main Street; :Hyannis,MA 02601 Office: 508-8624644 Fax 508-790-6304 Date: z` 11 Sewage Permit# ZCM5 ,05 Asses - sor'sMap/Parcel' Installer& Designer Certification Form - Designer: ��!I1�� g �-�'k\y�`�er�n,'��:�+-� .-- Installer: G , , Address:. (r.S Address: l- On was issued a permit to iristall a (date) (installer), septic system at based on a design drawn by (address) dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved.changes.such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10'.lateral relocation of the SAS or any ve ion of any component of the septic system) but in accordance with State & laio s. Plan revision or certified as-built by designer to follow. Stripout (i ff VIAS ° cted.and the soils were found satisfactory. o oDEA �. CIVIL r i No.48168 �90 �FG/S TERF� Insta er s ignature ���fONAL ff (Designer's ignature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE.PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK,YOU. q:\office forms\Jesignercertification formAo'c 1J.1-4u: rreparanon or rians ana apecincanons tT The plans and specifications fv every on-site system shall be prepared as follows: (1) Every system shall be designed by a Massachusetts Registered Professional Engineer 9 or a Massachusetts Registered Sanitarian provided that such Sanitarian shall not design a system designed to discharge more than 2,000 gallons per day pursuant to 310 CMR 15.203. Any other agent of the owner may prepare plans for the repair of a system.designed to ischarge not more than than 2,000 gallons per day pursuant to 310 CMR 15.203 provided they are reviewed by a Massachusetts Registered Sanitarian and'approved by the approving authority; Every plan submitted for approval must be dated and bear the stamp and signature of the designer, (3) Every plan for a new system or plan for the upgrade or expansion of an existing system which requires a variance to a property line setback distance,must.also reference a plan which bears the stamp and signature of a' Massachusetts Licensed Land Surveyor in accordance with M.G.L. c: 112, § 811); (4) Every plan for a system shall be of suitable scale(one inch=40 feet or fewer for plot plans and one inch = 20 feet or fewer for details of system components) and shall include depiction of: (a) the legal boundaries of the facility to be served; (b) the holder and location of any easements appurtenant to or which could impact the system; (c) the location of the all dwelling(s)or buildings)existing and proposed on the facility and identification of those to be served by the system; -(d) the"lacation of existing or proposed impervious areas, including driveways and parking areas; (e) location and dimensions of the system (including reserve area); (f) system design calculations,including design daily sewage flow,septic tank capacity (required and provided); soil absorption system capacity (required and provided); and whether system is designed for garbage grinder, (g) North arrow and existing and proposed contours; (h) location and log of deep observation hole tests including the date of test, existing grade elevations marked on each test, and the names of the representative of the approving authority and soil evaluator; (i) location and results of percolation tests including the sate of test and the names of the representative of the approving authority and soil evaluator, 6) name and certification number of the Soil Evaluator of record; (k) location of every water supply,public and private, 1. within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply wells, 2. within,250 feet of the proposed system location in the case;of tubular public water supply wells, and 3. within 150 feet of the.proposed system.location.in the case of private water supply wells; ) location of any surface waters of the Commonwealth, rivers, bordering vegetated wetlands, salt marshes, inland or coastal banks, regulatory floodway, velocity zone, surface water supplies,tributaries to surface water supplies,certified vernal pools,private water supplies or suction lines, gravel packed or tubular public water supply wells, subsurface drains, leaching catch basins, or dry wells; and the-location of any nitrogen sensitive area identified in 310 CMR 15.215 within which portions of the proposed system are located. (m) location of water lines and other subsurface utilities on the facility; (n) observed and adjusted ground-water elevation in the vicinity of the system; To) a complete profile of the system;. (p) . a note on the plan listing all variances to-�the provisions of 310 CMR 15.000 sought in conjunction with the plan; (q) the location and elevation of one benchmark within 50 to.75 feet of the facility. which is not subject to d;slocation or loss during construction on the facility; (r) when dosing is'proposed, complete design and specification of the dosing system proposed including but not limited to dosing chamber capacity (required and provided), pump curves.and specifications, number of dosing cycles and depth per cycle; (s) when a Recirculating Sand Filter or equivalent alternative technology is required or proposed,a complete plan and specification for the system,including a hydraulic profile; (t) a locus plan,to show the location of the facility including the nearest existing street; (u) the street number and lot number, if any, of the facility; and (v) the materials of construction and the specifications of the system. iJ.ccv: rreparauon of rians ana anectncanons The plans and sperifications for every on-site,system shall be prepared as follows: (1) Every system shall be designed by a Massachusetts.Registered Professional Engineer or a Massachusetts Registered Sanitarian provided'that such Sanitarian shall not design a system designed to discharge more than 2,000 gallons per day pursuant to 310 CMR 15.203. Any other agent of the owner may prepare plans for the repair of a system.designed to discharge not more than'than 2,000 gallons per day pursuant to 310 CMR.15.203 provided VI they are reviewed by a Massachusetts Registered Sanitarian and approved by the approving _authority; (2) Every plan submitted for approval must be dated and bear the stamp and signature of the designer (3) Every plan for a new system or plan for the upgrade or expansion of an existing system which requires a variance to a property line setback distance, must also reference a plan which bears the stamp and signature of a Massachusetts Licensed Land Surveyor in accordance with M.G.L..c: 112, § 811); (4) Every plan for a system shall be of suitable scale(one inch'=40 feet or fewer for plot t plans and one inch = 2U feet or fewer for details of system components) and shall include depiction of: (a) the legal boundaries of the cfacility to be served; (b) the holder and location of any easements appurtenant to or which could impact the system; , ::V (c) the location of the all dwelling(s)or buildings)existing and proposed on the facility and identification of those to be served.by the system; '(d) •the'location of existing or proposed impervious areas, including driveways and parking areas; (e) location and dimensions of the system (including reserve area); 4 (f) system design calculations,including design daily sewage flow, septic tank capacity •" (required and provided); soil absorption system capacity (required and'provided); and whether system is designed for garbage grinder, (g) North arrow and existing and proposed contours; (h) location and log of deep observation hole tests including the date of test,-existing grade elevations marked on each test, and the names of the representative .of the t approving authority and soil evaluator; (i) location and results of percolation tests including the sate of test and the names of 1/ the representative of the approving authority and soil evaluator, IZ ') name and certification number of the Soil Evaluator of record; (k) location of every water supply,public and private, 1. within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply wells, 2. within 250 feet of the proposed system location in the case;of tubular public water supply wells, and 3. within 150 feet of the.proposed system location in the case of private water supply wells; ) location of any surface waters of the Commonwealth, rivers, bordering vegetated wetlands, salt marshes, inland or coastal banks, regulatory floodway, velocity zone, surface water supplies,tributaries to surface water supplies,certified vernal pools,private water supplies or suction lines, gravel packed or tubular public water supply wells, subsurface drains, leaching catch basins, or dry wells; and the location of any nitrogen sensitive area identified in 310 CMR 15.215 within which portions of the proposed s stem are located. m) location of water lines and other subsurface utilities on the facility; (n) observed and adjusted ground-water elevation in the vicinity of the system; ; f(o) ` a complete profile of the system; (p) a note on the plan listing all variances to the provisions of 310 CMR 15.000 sought in conjunction with the plan; .0:0 the location and elevation of one benchmark within 50 to 75 feet of the facility which is not subject to dislocation or loss during construction on the facility; (r) when dosing is'proposed, complete design and specification of the dosing system proposed including but not limited to dosing chamber capacity (required and'provided), pump curves and specifications, number of dosing cycles and depth per cycle; (s) when a Recirculating Sand Filter or equivalent alternative technology is required or roposed,a complete plan and specification for the system,including a hydraulic profile; Wj a locus plan,to show the location of the facility including the nearest existing street; the street number and lot number, if any, of the facility; and v) the,materials of construction and the specifications of the system: �I.I .-.1 . i .-.i.I,:1i ' Town of Barnstable .. . I. # � --1. rate I . . . Pao f pit partntent ornegulatory Services j I . - . . -7 . . I � . . - � : . . I . . 1. . - I I I I . 3 ublic TIealth Division Hate '"2-5-0 9 s eA... II. .� . . I2.. Iw+arABr a I IIj�-iE..,!!,:�j:i.:-1 ZI��.I q,1,I:r-�.,-/1 Ii��:,,I MAG ,I�:..IIJ��-.J�,,...,,1.,.iI.;';I---�2I.r�I;.;�2 4..rII�-i4-1..Ir 1-,:�..:,:,::.�..,i�'11 r�...��,.i��'-...K�..:.I:1:I..1.I IjjA I:.,i�.I 1�.,O1k�,+!.;�r..���,!!.::.,7]...—�,,!�,i'..,"-!'.,i'li:.:-'-!".!.+,i..�1i,�LO.`i.-,�.:%.i.�o�`.:9,.,'�1.-.�:+..,i�I1i1� )i.**.-.�.I,i 1,-...I.I,�,�M-..".�,,:, '.,.MI'.�--,:.-.w%i�.��,,r.-I.Z�:I�..%p-.1�.b.���w.,:-7:-,':N�r....:� ,�—I+-!.'�...-,:...—im-..n�::...;FiIw.�..,,.I,...��:.����.�.�:,,I�...1�-..v..�_::�,',i.�r.�.,'%,....+.I.-�i,....I 1;Pr.,....?.:-�.i.,1-:,-..__:�'_,r-:�_r.::I..:' .,.;,.r..-,--r.:�'��rr/....e,,��,��,'. �:I-:,-rr_4.-,i�-��.I1,,,,r.I�.:j,--.,,;:.I'..�,,.I.��.�.. ,�..."A+-,:.�1�'�,�-,'-:-- :��:.:.r,.'�,_....-.�.-;-I-i'i-:.:,�:,.....-,.,7,-..-,,�',I 1..,�r..��..��,%�:.,._..t;:,�...,.-.�.:-,�I:,._.rj-.�I"Ir,��—-+�1...-rf-- ,i.�II.,I,,-,�I1:-j�-.],�.,�;-"0-.�,. -��'r+..�,1 H��1,�,.�r 16lq." �� ` I .2o0 Main Street,Hyaintis MA 02601 _ j tFD Nlld 6 I. I 4 i I _ x=. .. . __ Time Pce P . /,DO DO Date Scheduled -,.: 1 . . ., p • iJ h. , Soal Suit vilay-Assessment for Sewage Disposa•/l/) a/'�p/)///� 1 ' I 11 /.�,II .. dry ", }V.•_' Ik-. �;Y.A {.I nga', ekrJ:�I'7 C- w,U;, td By: Pertotlned By ._..1'I.,!�,:,y.r1I,—..!��lY 7�.�-�.!j�'.l��,.,,r.:��`'.,.��iAi1q.,�-v!��,,I:r'!I!:�%%��.,l��':�I,�r'r i�:�-�,I-�",I�I.:.r:.� ,.-�,I--...-,,1 1-�iI�I1;;.Ii;1.�I—.—I—;.���u,�-,�.1.--,2.:7,�,,'I�-..--L-I-,'���.��'�;..-7�..���Ir 1r,�'f' LOCATION ,;GENERAL INTORNI . ION rr y . 1 i 1',•: • Owner's Name rk* Na C$. /7G�. , rKS Location Address f7�G!°i- 101A a.rL Per . 0s•e r v i U . 1 : ,. Address 4A), mgu-n 51 . Os4cXY,)It, 7p. 6.26.4 Assessor's MaplParcel: m /4 4 a pL17.el QO Cngiiieer's Name" ,Gh .rn ' 5u//iYCt2 �� NGW COTJSTRUt:fION /: ` REPAIR Telephone H 5 0�- y 3 YY aJ1-3 290 �7 5 e Q see s 4 p ` ` I - Slo cs % t3A 'it 7 i a! urrace stones N A ' . , Land Use ke-sl- e7l`la 1 p O . : 1w . . I I , � - So- tt . Distances from: OpelrWater Body !(05 O I`T R Possible Wet Area 27,O fl Drinl.ing Wnter.Well , ' �- .{ (ab+ . Drainage Way Sb0 R, r Property Line .. . . n Other N j n . . . STCY (SUeet name,dlmensioits or lot,exact locations of tEst holes do pue tests,Iolale wetlands in proxlmiry to holes) I II, : . .. ) I, I . t .. . . . . . I , ' , r, . f�1 ItF . t �„ F TIt_3 �0 ' t - �► �, _ Q -_ + ,1 y . . N I i f;-4 .I r , 1 1 w.--: . ,, . N �_ 5 �.-f ii ' v h' ° , u t O § - .",r 'a `9 \1 1 �` 1 lI j, aI �' § T 7 I I -� ' ; P i i, # { I , -.9 Ij . y r I `1 s F Depth to Oedrock SOa ' j Parent material(geologic) t ,F hI 1{ I t 11 t. I t! 4 r. x iF �,�� I Weeping from Pd('ace Atf� j De 400 Groundwater Sian liig' i Hoi t I I I e l y ', I :I r 1 , (( ,rye \ �JWC.W 1'l �1 Cslimoted Seasonal Hlg .(i ndwater d i� .S try 4 6 `P p I a:f , AL tXGII WATT R'�A13 1 F DET 0j ' S,�ASON, u , 1 (I' ; + �' ill Method Used. I f in 'De Ut to soil mottles ihpth Obseri a tending in o I �t e, ; ! i Y 11 Gr p�e'.tevpter Ad,ustin '' `' L .a.1t Dcplh to weeph g ontsl eoQbs� oiw '` evclk ' I Aldj�racloc°______'Adjz Oroondwalcr Level d o 1)at ! :, In g Weli 1 I L k Index`Well g g ( ' 1 t ` ll; a I r��.t r o r J r j pps' Pj ;.1 I'IVLA �qN 1L►7�Fi t4' lr�atli (Illu`L TimE �-�' $ tp{s 5 �' 4t � # 1 t �_; �I� I . I�r�l �: h �I�� HrVir� .f '.t�lf'f ��I I4 ; 41 '-'I+i� �,�.'rl 8:; , k, Observation 1 Tlltle at 9;' -x--e I t Hole g f 1 a F z ?r 4 e 'I ��k },� I I `:� 6r�y4��1 s I �r pia 4 4I I tl.� �:, N t'. I ,'` t� Y p ? i ' Z} 7 I, Clme atb I °, pUt of Pcrc .I sl . f 1 I p ( i j Time(9'+G'l Start pre saal Time Q{ 1 k_ 6 R 1 �. r 6 1��*,,t 1 - a :� K,. i p 1> - . I ,1 afl-�+ :I I I s� End.Pre-soak l� rl I .' S I I i - ILate Nlin/Inch` t I ;;1 + i h ititeTailed AddiUonai Testing Needed(YM) Site 5,uitabilityAsses§me+nL Site Passed .: LI �`' t i 1 1II Uservahon Hole Data To Be Completed on.I3ack--- Original Public Htalth i3ri ion 1 . i' I g I I LJ I ! I , ;� , ! I _ 1 I, i L !, ***If colatlol t t is,t# b '0 due c wttlun 100 of wetland,you must first notify the i t i�', i O I 's i " 1 Noa* twu s,Iasi a i s sf one(1) ieelt Prtor to begtnnutgi,. 1 1 I I I , I ' I 4Qb f -- P3LLP OBSERVATION HOLE,LOG J:101c It Depth fium Soil Horizon Soil Tcxturc .Soil Color Soil Uthcr 311tlhco(in.) (USDA) (Munsoll) Mottling (structure,Stones,lluuldeis. Canelstanov YAQr1Wd) ___ .I p `4 8 1=1 Wit„ qb.^fib • ( LOAM14 tJ (e R`i �� Ya Inc-0 5RM� ��-g4 �� w :F o s `d`t-1Zo L "' t 0`I . . . . . . . .. . . , - .I . It, . . .. ; ; LL DEI';P OBS�RVATXOKHOLE.LOG Iltile i' 7 Depth from Soil Horiwn a 1 -Soil Texturt Soil Color Soil Other Surfaca.(in.) - f (t7SDA) (Murisell) ' Motuing :(Structure,Stoncs,.Douldcrs. . IT - Consistency%Gravcl) Ii :wa tad . 0-57 NOVA * (C- 3 . 5- 131, R ��'D' to .z 13 . I j Its,��^ -� lay( .,� Y i L40'SYo', L L g .�TY ee( �� Z >^nt DEIGI R OBSEI VATION HOLE LOG ' Hole#^3 Depth from Soil Horizon 1 'Sbd Tezturo Soil Color 1 Soil Other- Surl'nce(in.) (USDA) (Muuscll) Moi liiig (Slruclive,Stones;boulders. . Co i islcncv °lo UrniclL 0 Y . CUAwn ,-a . . . . . . 6)-lz . . A , n i . tZ'2y C6 j 1 . . 2N-4Z c , 'I _ I . . . . Sy 12c1 C. . . . DLP OBSPyA;TION kIOLi';LOG Ilule II Depth hum 5riil llotkini 1' L Sol Texturo, .Soil Color Soil Ot. (Munscll Moulin Structure,Stones buuldcrs: . Surface(in.) ((�SD�1)11 ) g ( VVV Consistcizy "�o Cravcii p t7 SD C�L� x 1 f . �'' 1 �j . ��4 III h S`� 4v:' }I �� II I..�Il ti 85 ' V +, F I , I} I F tl I�f , q l I d ,�f �x IIA !I# II f/��Ni , i lit #LII pp 1�" C;z I I �i. �# .I.., li! it rpa 1 i a -..� a I r 3f II , 11 1 C ,[ ,' liC1'1f �{ I i Ija4iIir1# x= f� i t 4 3 I. a 'k: r, I l S Iy. r ! f f A i 7 G 1 1 f t �,_ r g,;' Nlootl nsurancet 1Na y, i� i N ,a ..},1,YI s +Ip a } tp r' f, f t ' Y " # L P �. i,l# F §� Er r I # N AbOVe SUS yE. O(�b0ui a �: i 1 t(� 1 :i( ; ; I#r .� sa *I! ` x�i� t 1 # f,;II i i �k }�ji `+Ct Gr$. W` �41 CjOd�r r 6 k ?-) I '1 E, :ii�fi ii �9( cs �€ 5:?�c.F n (�. ,.� Wilfiin 50DF�e und6iy IA xl I ` r "� - rie 11s./ rr, ,r , Y f�r..[# �',r:,f.wjl c ;; � t �'�.f # `.'- $r �t�t) !� D1 e +,�r �i{.y f }sa�j�' ^1S Ct'; a ,� # I 4L � # rY 3 t+ #5 F 1 + i Wdltin 100 ye r od bounds y � i IVO �_ y rrtL[ x i I d .'.! � e lh of 1Vattlrnll c urrltt �P r. t t�s 1, ut ial ' ° , ;° { j .,::#f°t r' .} .`' toti�tnatertl exis ut a11€tEets observer!titrouglwnt the Does`at loasi:'. dkW fe t nalu I c r u� p l area,preposcd foi tli j o t a66 t ti s 14 G a i; # I c� _s re, a I' "�- y oidts mateftal7 + If not,�ihat is the�e t f�iut t'rI .. t�1, h f ! { �y s t l f I.' $ ,. R' i I ik:, �� 11 1 ' L 5{ r: Ccl t�catidil ar E',` G �}Ii f1' .�t,, F ;. , ." ► 11, d assed the ab��evaluutor examination ttppcoyc�b the 1 ,, s r ; a 1 t:ertify,thnt";on , l Y�Y I- f.Envit, i cntal ro c i n t♦t ii at the above unlysis was performed by mo cons"fstcnt witL fyo attmout;o p y A.,:- t, I fl the i equtrerl,tramiti` ttiso nn ci< rien o escri' # X 1 !i +r '4t 4 1: t 1,l Y bate ti[Oq d Sig nature "', ;1 . l k i r ;t LI Q 11CALTIUWPIPkd i i " L '' �I # Ytr a� a u L�1L I IL IL 4 1 , 1 �'r i �,a,l ,� d b s i '` r Ai; F b.ter ; �� r ;t # 0 : - - ... -- - " - _ ---- - - I 7U ® ® FER 4�^I' COPP 0 W --- _.__ ------- ------ ------ -- Q z 0o TR Re I Nc arR iuRe e e rno 0 � W Q . Lj M ,•D !4 UnN R - •IG pWnN „A T%OI LRa !L iRU UR! W_ W N C O CX _I eNl c onK Q n/ 0 Ll N , I Q j REAR ELEVATION a F -EXISTING STRUCTURE tAt G....NIPOUT TO lKIlTM4 DCwTCN DAfM - XI 7 Vt TO cOLI111N - f.).I11 Tf COLONN / I LII I i - U VI f.f•I/•Tf cOlunN ��� - •�. I 1 - I 1 - _ COMPOSITE DECKING yy//yybAli OAYIO s •O a A4 a I I I R ABOVE ON RUBBER • 1 I ., I I . 4— T OP BI E) I I I E; O E O R B E I I I I ROOF- 1I - 1 1 II II 4 R EXISTING _e• j i I I; ROOFOOF STRUCTURE II I•!L COLunN jj; li REPLACE W/RUBE R. • >i i� I I I I V• +' I I ROOF AND DECKIN I TO C—N II II I b - I I•'l,II I n• •lao of ea a �epod i i I _ _______ r••ORaN w n aoe •: ..............lC.L0. .. .......�. ':.r-. f I I i I 1 i R it��reCAe rc..nN I i 90/1 eweM �oNe rTc w I ; u.a l I LINE OP EXISTING BLUE S70NE PATIO ExISTIxG A C I T I n•IA PL COLu„N - - - •I. EIY Dw l4 GOLNIN LINE OP ROOP.OVERHANG ; II ).f•V•te COlunN I/ --� •- --' „ 4 t' If•1•I/1 TO COLUMN Y PI ELEVATION .. ••• E ___________________________ 77 I N•DA CONC PIlR w C e ____ f Ij;.ft.uION.IT. nN.oN.R.Tc ................ _ TERRACE x.a ; {.....-i - PLAN 1 NEW DECK 'EXI9 TING t MATCH EXIST - ! TERRACE PLAN A 1 R TOWN O/F�BA/RNSTABLE LOCATION �a �/A ice cS`• LC/�hA/Ii9 SEWAGE# -VILLAGE (1S' fery , //C ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /v�4 D 6`�/, — //.d 0 LEACHING FACILITY: (type) r&/a—33 Qom- h��?0 (size) I X /O � NO.OF BEDROOMS II BUILDER OR OWNER IF-0 PERMTTDATE: , 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 f� . Q � -Poo/ 19 {_ TOWN OF BARNSTABLE I;.OdATION 1 t4,41"i s f SEWAGE # vJ AGE Q s Lr v i r ASSESSOR'S MAP & LOT & INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 3�0 LEACHING FACILITY: (type) %h (size) NO.OF BEDROOMS BUILDER OR OWNER S to / PERMTT DATE: `7/i 1-1 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) lli57 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of aching facili Feet Furnished by, 25&= // a� a � /��• t. F`• r�,_ • _T•� r �I���� .. � �,- l r �.3 v � - a �'� ^� g y _ . �ktAP 1 &4- �Aacr✓� 4- No. f _11 Fee Ia(� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH-DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0ppYicatfon for &zpaai *proem Construction Vermit Application is hereby made for a Permit to Construct(V)or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 421 MAIN S'7". CJ S'j�2vl C.0� L—:Ovul-raD Cz=&ILAI4D42I AN Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. a '-AvI t-t_15- rF7� q l3 Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ✓) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 9C)rj gallons per day. Calculated daily flow 990 gallons. Plan Date �t�`Z3, lggi 1 Number of sheets t Revision Date 46 �, t9q`7 Title SITE R_A4 rapt- 4-Li 5ov f kA 4tlJ 1r-' etil�lt-c.g Foe GDwa✓r b 1P54AJ4D4e4 arf I Description of Soil CAOVP2 G'oAaAG _"ANZ� I t Sail. CnrJStul/ nOr1 ` 6rt✓7643 AAA.12plUe� Nature of Repairs or Alterations(Answer when applicable) f X KT11Je, C6ss,PcyL5 Tb `P F_ Pt)ly pu::b 'L,I Ft LL�M LU tt4 G-6`7�I� 6aA alvc 4 e_ KA 4TEMa 4 L� 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 7,7, ificate of Compliance hasbeen i e is Board o eat Signed Date Application Approved by J0 S' Application Disapproved for the following reasons Permit No. (A P Date Issued '7'-"��... �+..-�`� , tom. ` y y w-. .. .-, .'r4.... _ __.�`. .. ,{� _^'_ � ..•.'.., � _ , No. / . / � z �. �� +, Fee • 1 Da . THE COMMONWEALTH OF MASSACHUSETTS ,TOWN OF ARNSTABL'BLICHEALMU+ O =P4 , ACHUSETTS ,- 01pprication for &'!#og-4r *pttetn Construction-Vermit ° 'Application is hereby made for a Permit to Construct( }or Repair( )an On-site Sewage.Disposal System at: Location Addres3 or Lot No. Owner's Name,Address and Tel.-No. 421 grit 4 0 ' ST• G7 STt---YL.vi C.L ` nwA,zn t.S14Ai4a A2-I A t4 �,C> oy,-G2s � MA,7We—1 I0C 4743 lolly ` Fv 31 o v 7 r�+av t t.1.,E; G Installer's Name_Address,and Tel.No. Designer's Name,Address and Tel.No. �aXTs►z r I�yE 81 b tit A Sr o T'hmy I L wr q 13 Type of Building: - Dwelling No. of Bedrooms q Garbage Grinder( ✓) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 99) gallons per day. Calculated daily flow 910 gallons. Plan Date.T5, I lel 7 Number of sheets I Revision Date wG *zo. I q q'7 Title s Tr, T;LA►J AT 421 5out4 A1AW 4r e7TS"tL.LG rjo2 GDwArtZ> 195"NO49IA4 I"- 40 Description of Soil GAeVSa, (:�v A"S S ,qtA I4DL S01 L. Co��e .✓pT+aJ 4MVj ag (A Alp 1 JJ 4a �{ Nature of Repairs or Alterations(Answer when applicable) 1!X KT11J& C -_aT1CVL 6 TV 'F3B PUrop1:m L Ft I I. n tV ItlY ' CLEAQ 6WA1JVL0rt_ hA AjjV21A[ter+ .Date/last inspected: 60' 2lo'e)to � 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 unti Ce ifi- cate of Compliznce has been i e is Board o a t +�} . Signed Date Application Approved by Application Disapproved for the following reasons - Permit No. - y Date Issued r _THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS 15 TO CERTIFY that the On-site Sewage Disposal System installed or repaired/replaced( )on by r^ -.., for a�- q2/ Imo'Ct^ 1 -f P-Y� j = h s been constructed in accordance ; with the provisicns of Title 5 and the for Disposal System Construction Permit No: 9 7- dated Use of this system is conditioned on compliance with the provisions set forth below: No. V6 , Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mid Dal * sem Construction Permit Permission is hereby granted to to construct repair( )an On-site Sewage System cated at VY4 4 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. All construction must be completed within two years of the date below. Date: �'�''_� �,.�' Approved b � f 1 TOWN OF BARNSTABLE LOCATION kL/,a ,, S f SEWAGE # VILLAGE sc�,r v i I r ASSESSOR'S MAP & LOT f INSTALLER'S NAME&PHONE N0: --�> SEPTIC TANK CAPACITY c LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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) %'J Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facilityZ_. 5�t /';?,l. Feet Furnished by !t c'?U� r N Commonwealth of Massachusetts. Executive Office of Environmental Affairs , Department of pp 1 T Environmental Protection k Fly William F.Weld �`L Goamor ��< Trudy Coxe Secretary,.EOEA David B. Struhs d*;7' a F' Commissioner ..� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CmA:iN l�eu5>✓� CERTIFICATION Property Address: qCx i1�(Rta. SJ Address of Owner: J O!'�l� C o C rp L_L Date of Inspectionr!� (If different) Name of Inspector: I o 10Sr Company Name, Address and Telephone Number: pn 00 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ZPasses _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: i Date: 'C(w The System Inspector.,^'shall submit a copy of this inspection report to the Approving Authority within thirty (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 repor, to the appropriate regional office of the Department of Environmental Protection. The original should oe sent ;u :ne system owner and copies seni to the buyer, if applicable and the approving authori;y. 0 INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: / which indicates that the system violates an of the failure criteria as defined in 310 CMR.15.303. Y I.have not found any information cy Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: A Y One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street • Boston,Massachusetts 02108 • FAX(617)SWI049 • Telephone(617)292-5500 �� Printed on Recycled Paper f, f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: qd, Moi11, 5(• 05iev-V A'e- Ownerw�\tA G.rrAl( , Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) I� Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The Svstem has a septic tanK ana s011 aUSOrptlun system and is witlllll Ic)V ICE1 to a sunKc watEi supp!! or trlbutai)' to a surface water supply. _ The system hay a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The systenl has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. D] SYSTEM FAILS: /-"1f I have determined that the.system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �1,, CERTIFICATION (continued) Property Address: ��j Ii ct i N S i Owner: C-rAv ro\\ Date of Inspection: D] SYSTEMA FAILS (continued): 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped I Y Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the sN;stem 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 "ater suppiy well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 'yaI fy\ Owner: CC"V-'ro V -Date of Inspection: Check if the following have been done: _Pumping information was requested of the owner, occupant, and Board of Health. ZNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates duringthat period. Large volumes f P g o water have not been introduced in h to the system recently or as part of this inspection. IL As built plans have been obtained and examined.i P ed Note if they are not available with N/A. V The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary_ Y or industrial waste flow V' The site was inspected for signs of breakout. _All system components, excluding the Soil Absorption System, have been located on the site. _✓The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or /tees, material of construction, dimensions, depth of.liquid, depth of sludge, depth of scum. y The size.and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. V the facili;) occupan,s, if d`.`'ere^t from; o�;ner! were provided with information on the proper maintenance of Sub Surface Disposal System. 7�1 (revised 8/15/95) 4 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: qal l QJw 5 OSTzruy�1_e Owner: C at f o l Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: allons Number of bedrooms: Number of current residents: 4 Garbage grinder (yes or no): /V Laundry connected to system (yes or no): Seasonal use (yes or no): Water meter readings, if available: !Y Last date of occupancy: S,j OAtwe.r cr qS COMMERCIAUINDUSTRIAL: Type of establishment: Design-flow:_gal Ions/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, iif available: Last date of occupancy: OTHER: (Describe) Last date of occupancy. GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (,yes or no)-6/ If yes, volume pLimr)ed gallons 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) Other (explain) APPROXIMATE AGE of all components, date installed (if known)and source of information: �� �/rS n In Sewage odors detected when arriving at the site: (yes or no) N (revised s/is/95) $ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1194 1Yl aiFu S' Owner: Date of Inspection: SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of.liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from botton' ni From 1n hnti:n!r of outlet tee or battle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8i15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION TORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Ca rf- ,�1 Date of Inspection: (D Ck(A TIGHT OR HOLDING TANK: jlocate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP other(explain) Dimensions: Capacity: gallons Design flo,,N,: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:/ ' (locate on site plan` Depth of liquid level above outlet invert: Comments: (note if ievei and dstri.ouiwt, eyua:, e\.dence of solid ca,r�o\er, evidence of leakage into or out of box, etc.) PUMP CHAMBER:: (locate on site plan) Pumps in working order(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised B/15/95) 7 SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION"FORM PART SYSTEM INFORMATION {continued) Property Address: tU � d�serva�e Owner: G Ac't cc1 Date of Inspection: SOIL ABSORPTION SYSTEM (SAS);_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number._ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) n Sari S dr✓l V nZ /[� T �-e__ Q[--,ovN A,, na CESSPOOLS: (locate on site plan) Number.and configuration: Pr"YYtax l -i— OVey-gnw Depth-top of liquid to inlet invert: Depth of solids layer: Q` Depth of scum layer: ./it . Dimensions of cesspool Materials of construction: "�["'-1L Indication of groundwatc . f%4 o N t= inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation`etc.) 5',rji,,S o4C 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.) (revised 8/15/95) B SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: (_l a t w�t� '✓ t\�o.L V„ — _ Owner: Coy -O(k Date of Inspection: (o ��-C,b SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' S d loo z t> 4j DEPTH TO GROUNDWATER ` rqp w(Acr� Depth to groundwater: / L feet method of determination or approximation: c�rZ U vim- c �� nc�LS h�� n� ems' 1 D FT tie (revised 8/15/95) 9 vv4,001" Commonwealth of Massachusetts ; Executive Office of Environmental Affairs47 Deialartment of r Environmental Protection William F.Weld Governor Trudy Coxe Secretary,EOEA David S. Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM // PART'A l.l-t�(tivc�Qva�rs� CERTIFICATION Property Address: 4/a 1 56:.'t�n��Kty JZQ a`>Zrvu kkt: R',� Address of Owner: Date of Inspection: (V-a,(._q (If different) Name of Inspector- j LL-L�,,e_ Company Name, Address and Telephone Number: VN0-cw(ie— CERTIFICATION STATEMENT I certif},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 inspection. The inspection was performed based on my training and experiencg in the proper function and maintenance of on-site sewage disposal systems. The system: L/Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signatur Date: 6.g jll The System Inspector shall s mit a copy of this ins ion report to the Approving Authority within thirty (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 a PP P ro ri to regional office of the Department of Environmental Protection. P g The origina! should be sen; tL. ne sysiem owner and copies seni to the buyer, if applicable and the approving authority. ' INSPECTION SUMMARY: Check A, B, C, or D: A) SYST M PASSES: 71 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 A is Printed on Recycled Paper F r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: qa); )'I�IR;t�l c�. OSzv'►`� Owner: Cs•,vyr o kill Date of Inspection: . B] SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 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 the public health; safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Ihp ,v5tem nay a septic tanK ano soli absorption system anu is wlllmu i00 fCei iu a Su'Ce VvaiE s6pp:) of trlbuzar) to a surface water supply. _ The system ha, a septic tank and soil absorption system and is within a Zone I of a public water supply.well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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• D] SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. _ Backup of sewage into facility or system component due to an 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ct t iv 5• G S 1 e r\ t(If Owner: C.—-v-o\` Date of Inspection: Dj SYSTEM FAILS (continued): 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apple to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a public water suppiy well, The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 6/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: y'0L -T C5,s-\" Owner: GuY-v-o y� _Date of Inspection: Check if the following have been done: Zumping information was requested of the owner, occupant, and Board of Health. `<None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. /jl�As built plans have been obtained and examined. Note if they are not available with N/A. The facikity or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or in waste flow /The site was inspected for signs of breakout. �All system components, excluding the Soil Absorption System, have been located on the site. fThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or /tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. +hC occupants, if d:'?ere^t from ov;ne-, were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/951 4 • .Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION Property Address: yo� /r►'i t 1'j t i. 6 S T C'1-rk(%C-- Owner: 6,vro kk Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: _gallons Number of bedrooms: Number of current residents: Garbage grinder (yes or no):_� Laundry connected to system (yes or no): y Seasonal use (yes or no):�� Water meter readings, if available: A Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_ allons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title S system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information. , r%r-r -rW 5 e,G 1 1!u-/ System pumped as pan of inspection: (yes or no)�[ If yes, volume p.imppd. 140,,2 gallons 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 'ya/ i7(gI1'( 51,pS(-zrY})�F Owner: C arf o� Date of Inspection: SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Sludge depth: Distance from top of sludge to'bottom of outlet tee or baffle: 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage;etc.) GREASE TRAP: d (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle: Distance from bottom nt «tam tr honor^ pt owlet tee o,b2tlle- Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/:5/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:, 7 C�L M S► Si•L) rr y i(�Q Owner: cavro(� Date of Inspection: TIGHT OR HOLDINGTANK:L� (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_r( (locate on site plan; Depth of liquid level above outlet invert: Comments: (note if ievei and distrbut-�,,: eq�a:, e�.uence of sulid� co:r)u\er, evidence of leakage into or out of box, etc.), PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) II (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ya) mc(l N 5T- Owner: G,,rv'o l` Date of Inspection: \` SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) O . CESSPOOLS: cZ (locate on site plan) Number and configuration: t Oue- Depth-top of liquid to inlet.invert: 1 U`t Depth of solids layer. �LiI Depth of scum layer: Dimensions of cesspool: L .Materials of construction: '13L U4,Y Indication of grounds%ale pC.—c-- inflow (cesspool must be pumped as part of inspection) eS Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: / 'r (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.) (revised 8/15/95) B SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: G;vvrc,�l Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' SID 3Y DEPTH TO GROUNDWATER . Depth to groundwater: feet method of determination or approximation: I (revised 8/15/95) 9 QTION 5EW&C4E PERMIT WO. IN TALLER S NAE ADDRESS BUILDER 5 Q QNIE ADDRESS DATE PERNAIT ISSUED ' � -' DATE CONMPLI &MCE ISSUED : - - �; ..� ,w ..� - � , .. ;, , U .. � ` � `� / e � � �__ / _, i Z� .. No.•-'`----- - ...... F�$... .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H A �T1 H CA4,1;.L. ..... ---------OF....../.. C L ✓...................................... Appliratintt -for Ubpasttl Workii Tomitrurtion Punift Application is hereby made for a Permit to Construct ( ) or Repair (P.5"an Individual Sewage Disposal S t t: Locatio - dress or Lot No. ----- ..-_ - ----•- •••--•••---•••••••--=----•-•-•--•--•••--••--••.••-.-.•------•-•••••••-•---•--•.-=-•--•----••--•••. Owner Address P Installer Address Q Type of Building/- Size Lot............................Sq. feet. U Dwelling eNo. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder aq Other—Type of Building ____________________________ No. of persons-.-__-__.--___-__-----__--__ Showers ( ) — Cafeteria ( ) a' Other fixtures W Design Flow............................................gallons per person per day. Total daily flow-------------------------------------------.gallons. WSeptic Tank—Liquid capacity------------gallons Length________________ Width................ Diameter---------------- Depth.--.------------ ; x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area.-___--._-..-.__._sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation.Test Results Performed by.......................................................................... Date-------------.-_--------------------- ,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit--------_----------- Depth to ground water.--.----.-_--_-_---.---. �14 Test Pit No. 2................minutes per inch Depth of Test Pit-----------_........ Depth to ground water-----------------.--.-.--. 9 ------- -- 0 Description of. Soil------- __ V -----------------------_---_-----------------------------------------------....................................................................-----..__.----------------•-------------------- -------- UW ------------- ------------------------------------------•-------•-•--•-----------------•••-••-•-•-•---------J -- -----: .........------------ Natur of Re ,air or Alterations Answer when applica "' ______ ._- ®� . _ = --__r A,( ----- Ag Bement: �----•r" ,+�. `���'�. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitar Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en issue by e board of health Sign Dat Application Approved By --- -_ 2 Application Disapproved for tlae following reasons:.....................................................................................=.......................... 1. l ........................................ •------------------•-------••------------••••-•••-----•-•-••--•-•--•....•-•----•-------•._...-•-•.___._.-----------•••__•---- ................................ ate PermitNo................................................•------- Issued.••_- m--- ----------------- 1�'at s - No........... ........... Fine ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF E-9EAL .. /�/ ✓�._ ....------- OF..-... O�C� � :..' .............................. Appliratiun -for Diapusttl Warkfi T>antrnrtinn Przniit Application is hereby made for a Permit to Construct ( ) or Repail- ( 4-)--an Individual Sewage Disposal System at: Locati dress,; or Lot No. W wner � Address ,.7 ---- •.. �f � = ........ n Istaller -------•-•-----•----•------•=-------•- ------------------------------ .._............Addres--dresss-------------------------------------•--•- p T pe of Building Size Lot________________-____-____-Sq. feet Dwelling No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) p' Other fixtures W Design Flcw............................................gallons per person per day. Total daily flow--------------------------------------------gallons. 9 Septic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter---------------- Depth---------------- xDisposal Trench—No. .................... Width.................... Total Length------------------.. Total leaching area---------_.---------sq. ft. Seepage Pit No--------------------- Diameter•-__-___---._.__--_ Depth below inlet.................... Total leaching area.--_-.F'----__--sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY.......................................................................... Date---------------------------------------- Test Fit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ f14 Test Fit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ W --- ------------•--•------------------------•-•-••-•...--•--•-•----•-•-•-••--••......--....................................... -••-----•••----- DDescription of Soil------ .- .........................-................................................................................................................. l W x --------- ------------------------------------------------------------------------------------------------------------------------------------------------------ V Natu e of IF-e airs -r Alterati —Answer when applicable..-_._��. __l ®®_______.J_ ...f0 ----------------- 'D � A reement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—„The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b issued b thPeo r ealth. Sign r•l-- l-f --=--•- �i Dat Application Approved BY -- -•-- 1.G� - . '�----•------------ -------A .7 �;r� ate • Application Disapproved for the following reasons: ......-••----•--------------------------••--•------•-•----------••••--•....._•------- ,.. . .•........--•----•--•--•-•-----••----•-•--•----------------------------•-•----------.....---•--------...-_.-------•----......--•--•............�4D .We -------_..... to -----••----- t; PermitNo......................................................... Issued----- ......... COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tatifirate of 0.1nmplianre T S IS T CER IF hat the I iv idua S, age D' posal System constructed ( ) or Repaired :(� bT- �'� -' ��' i '..r�� ------------ taller Arai! at ` •_ ..... --- ...................................•------------•-•--•-•-•--•••----....-••-----'-----••--- has been instilled in accordance with the provisions pf :Article XI of The State Sanitary Co( as d/es in the application for Disposal Works Construction Permt'No ;. .9�............... dated..._�_..2._! _ __ 'J.. .. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G ARANTEE THAT THE SYSTEM WILL CTI N I FACTORY. DATE............... .............................. Inspector:-•--• ......................----------------------------------,.......... jji ' THE COMMONWEALTH OF MASSAC-iUSETTS BOARD oOf HEALT /� OF..... .... ...... ...: ... �.. .. .. �_ ................ •--� No. �✓ FEE ••--••-•-•.--.--- . Mgr � .eJn nrtin$t rrmit ,. Permissio t is herebyranted , iL, .......................... g to Construct (� ) pair,. ( n idual Se a Disp . System at No._ ......_ ... �- [. �e��l. �iOtt.. �. Streetas shown on the application for Disposal Works Construction r it _ _ ___ _________ Dated_____ . szY7..!..___~� Boa DATE......... �� r FORM 1255 EBBS & WA. REN. INC.. PUBLISHERS - w. QQ r, - . No. — --/ -- Fee-I?� BOARD OF HEALTH TOWN OF BARNSTABLE Application-*rVell Con0ructionpermit A plication is hereby made for a permit ts Construct ( �, Alter ( ), or Repair ( )an individual Well at: ) A4aI "AT. ©S ��1'e.9t If✓� ---------------—----- ----------------------------------------------------- 1 ° Location — Address ---M----�--°---�-�i--—1�-1—W------------------------ ---- -�� - -A ssses_s_or-s-Map and and Pa-r-c-e-1 00 Wau-"& -"U ° ---------- Owner Address Installer — Driller Address Type of Building ASSESSORS MAP NO: Dwelling----—---------------------------------------------------- PARCEL NO:-- Other - Type of Building------------—------------------ No. of Persons-----------------------------____------ Type of Well—y�.' YP — --------------------- Capacity------------------------------------------- Purpose of Well ------- 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 Co liance has been issued by the Board of Health. Signed --- ------------- ---— ------�------ date Application Approved B ___������ date Application Disapproved for the following reasons: ------------- --- ---------------------------------------------------------- /,�- date Permit No. d'!� �r P� - -- Issued-- �—`� - -- ---------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (✓S, Altered ( ), or Repaired ( ) by--- a,a _l1_-------------------- - -- - ------ --------- Installer a. 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. `' Datedd � THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----- - — Inspector- - - - - - - - ----- - - - - - - - - - - - - - - - - - - - -- ——-- - --- -- - I ��/ v No.�`g'''` --- Fee------`--- - `J `OARD 44EALTH TOWN BAR STABLE ZipplicationArVill Congtruction3vo it A4 lication i3 hereby imade for a permit 'to Construct Alte ( ), or Repair ( )a individual Well at: Location 'Address "Assessors Ma and Parcel — "` S / c' `.S'�.l t sa Ob/1 v'^- —--- --�- `'L X /`� PISU e- —` y � Owner Address — — — � S c�►n,..� !/ 3/ ��W Dot � /?,j U Installer. — Driller. Address ' e�� Type of Building , Dwelling----------------------------------------------------- Other -Type of Building ---- N,�4f Persons--------:------------------------y�I TYPe of Well --= ---- . Capacity— - - - -----—---— Purpose of - 7/ Agreement: N . The undersigned agrees to install the aforedescribed individual well ' accord rice with the provisions of The Town of Barrstable Board of Health Private Well Protection Regulation The undersigned further agrees not to place the well.in operation until 'a Certificate .of Co pliance has been issu d by tale Board of Health. gne _-- � "'�— -- -- ------ /l� Application Approved B ) M date Application ----------------------------------------- date Permit No. Issued-- ''t��- ---- -- date sTeHw@34i�i!�4a1i9i!i9i.34e9iY39are@o4ek�'�e±o@6�!e1o@o?o3\i9y�.o@6@6?&S3Qi9STG.9i939,t939o9A139i@6@F'.N3hL@34D'9cOd@itbwipilif3Ri!s'1e1.&Sil69aiTiWi7Ll31i434a!a0i9e!Ti1i432iTfi@imig39a BOARD OF HEALTH TOWN OF BARNSTABLE Certiftcate Of Comphance THIS IS TO CERTIFY, That the Individual W Constructed (✓S, Altered ( ), or Repaired ( ) by------ — ---- Installer CT at— -— --------_-- - 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.A—! - ® "'Dated�-=-_—% ---- THE ISSUANCE.OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- --__ _— --- —-- Inspector--------- ---------------------- - —----- 7 ..i9i Si'?i@i9ilit44O34!tli8i?i!3?6li�iBOGV'A•li9ill9iT�TG?Yt3ti.�3fYaili®ieilSli9?.4i9Y8i9iBil,.9i@b!Y@i@34i9iPiBr4®9Y?i4i9e..i�.sW..3„6!li'SiW ,BOARD OF HEALTH TOWN OF BARNSTABLE Veri Con5tructionpermit No. Fee Permission is hereby granted A A ---- to Construct Alter ( ), or Repair ) an Individual Well at: Street as sho on the ap lication for'a Well Construction Permit No. --- Dated- �- - /__- - - - - �, Board of Health DATE a --- a t No.,-jto-= ----- Fee--------z�-------- BOARD OF HEALTH TOWN OF BARNSTABLE Application-*rVell Congtruct ion Permit Application is hereby made for a permit to Construct ('�, Alter ( ), or Repair ( )an individual Well at: - Location — Address Assessors Map and Parcel — ,— —d SSs,, {tit/J✓ -- �r��__dWat. OS�C/0t /� 014&L t Owner Address Installer — Driller Address _ Type of Building Dwelling -— ----------------------------------------------- Other - Type of Building No. of Persons--------------_______—__—_—_______ r� Type of Well—�-p`��� ---- -- ------- Capacity------------------- -— — - — --— Purpose of Well 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 lla�CCee ifii to of Compliance has been issued by the Board of Health. L"-�" — — — -- /o /I,`? Signed ---- ---- -- — - ----�----1----- date Application Approved By __ _—_________— v (ce -?5P date Application Disapproved for the following reasons: date Permit No. — - —___ Issued------------- date _ BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( I."), Altered ( ), or Repaired ( ) - _ by---= --D J�S L6, -------------------------------------- ----------- 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. Dated---- —__ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--- — Inspector `,,.k _.. _ _. .. ....••+ .. .-_ ".. a_ _ . r n"5.--mow .w z No.- =----��----- x Fee-----�=�-9---------- BOARD OF HEALTH TOWN OF 'BrARNSTABLE ` pCice � ngtrurtionPermit t I 1 Application is hereby made for a ermit dtg vonsstruct/604 lter,( ), or Repair ( )an individual Well at: ' '"'Add :Assessors Map and Parcel r Owner q Ad/dress >L�!� =2_Ll�_•^J+v r_ 1— — — — -----— — ��- Q /�'� — L frdz" — <" v��1 fi -- - Installer — Drillers. f Address — Type of Building Dwelling "� Other Type of Buildl'g------------------===` No. of Persons---------------------------- �t Type of Well —-�=, —- ---------------— -- - Capacity-- — Purpose of Well Gof;� _a — -- ------— Agreement: u The unde.-signed 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•CeJtifi to .of Compliance has been issued by the Board of Health. Signed D ----------- — - - - �-- —�----- date Application proved By date Application Dsapproved for the following reasons:--=-___�__—�1� _ -- -------- -- -------------- - date Permit No. - -= - -�-�----� - --- Issued---=------=----------------- date Ae!e!4!i!-w!i!iti.alt.!e!d!ilile9i+3!!u?ii!iTe'4vlol'"4laPi1!s!i'fBliN:9rYliSi4G:F.i9i:lis4fMaBi169`:w.s!i�6469iRatiJeR84A�a.a!3"Wlfea4eT.gl6ES!s!6T4%!ri!GTGOI!4Tf!Y:e4!iti0G9a!!!$!b!a!r BOARD OF HEALTH TOWN OF BARNSTABLE t ertif irate �f Compliance �ry - THIS IS TO CERTIFY, That the Individual Well Constructed ( �), Altered ( ), or Repaired DhS�cti�< // � by---- ------------- ----- —_ Installer • at------ I'k a`"` has been instated in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as jescribed in the application for Well Construction Permit No. - -f'=_ y__Dated---: THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--------�. —- -- Inspector-------- ------------------ -----=-------- .!a�os&!t!:!a•o s�sieae+:!e!a!a!alsea+ave.ray,alas:+i!a8oarriaavae:eceal.ec�aeasdeaesxear!rayEcsn saeaems5waaae�sa!erlY+ri.b+rrpd2.ei�a�asm+v!!a+iswaas3�!a+64i:la.vaa!a�+a ea!a!:.« BOARD OF HEALTH TOWN OF BARNSTABLE Ivell CongtructionPermit No.w-j:?- ' LL Fee-- ---=---- Permission is hereby granted �. -- _---—-- -- ----— to Construct (�, Alter ( ), or Repair ( ) an Individual Well at: No. yA yA a t- . T- oS /-e" Street as shown on the application for a Well Construction Permit . . No.- ---- Dated L°-=- —� ��---------------------------------- -— --- _— ---- - - - Board of Health DATE — Q4� �. �-1�, �v�ad V � � •/ ' � . . , . . . rI -'x d m � v . . r O w N 0 { , ,. - - . E a a.4 N . .. . . Q+ 3 �' V � F .. _: . . - W' w _ t : - a � X. a . z c . x Z I . _ ` ;. . . . - , , W y » ( W w m • . 1. a . 3. 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' I _ • _ _ 11 - - . . - , - .- Day a - b 8n ff R _ j • _ '� � C o'� •Pubtic 0 Landii - •s.��5 ` • w5 q W. 14 o CE. !6 B y +r^. PK SET :::' EL 40.54' LOCATION MAP HYANNIS QUADRANGLE 40 Bouha FND. SCALE: 1:25,000 40 ASSESSORS f` MAP 164 PARCEL 4 5 ZONES: / 'e U AQUIFER PROTECTION OVERLAY DISTRICT 'Q) Z 0 N E C Qv`aJ oc\y ' �� ZONING DISTRICT: RF — 1 1 .I e3 �'i MINIMUMS 40- c� fit,► oo AREA = 43,560 S. F. CB/DH FND ko \ ' lip, �- z FRONTAGE = 20' EL s 40.94' n WIDTH 125, � FRONT SETBACK = 30' 0� o� SIDE SETBACK = 15' apt SQ y� #3 /247A REAR SETBACK = 15' FLOOD ZONES: V A B FIRM COMMUNITY PANEL � � No. 250001 0016 D 7 x 0 M •` TP ON rilpR r. �e••2 . v EDGE OF PAVEMENT / (%+ ` EL = 37.54' ��C ii;�GL/. �u�i t, 1992 \ Q P J O y S AS SHOWN ON THIS PLAN 4-FOOT WIDE <^�, \ E \ ` ,a ,�� SEE NOTE RE ORIENTATION/PLACEMENT PAVED SIDEWALK p �3� AG \ 1,0 NUMBER CB DH FND EL/ 31.45' z STAKE �9a `4 PARCEL AREA EL = 4 1' F �R CFO y,-D N TO MEAN HIGH WATER a S D%4 f }1t: � � \ � � 239,314 Square Feet f 5.49 Acres t NO NUMBER.. ` -NIP r ..Z 0 N E 9 ELEC METER \ ' 50, PIPE/WIREStN ' aPosepA CB/DH FNDAL- ? . •� �?s A%ETt.A 4D F A=NG BY ENSR i.,'k FLAO=G DA?- 6-25--1997 ' l z : l . .i IF't4.D LO:a:14tJ 8Y @A,X,TEfi ac l : . tNC- Q7-10, 11 & 14--1"7 sE5 LAO-DSCAPF _ _ Rf A t=oe 1 - d•PVC PtP>� � `. �,, 'r I , ! ! ! BORDMNG i V ^ 1 i------�3-8+ o, �4 `. . VEG£TA'TED .. _ 671 .. 1rtEltJ�ttD PLAN Vlr=VJ - L G IN!, "-NAMBEZ5 .. - Z 0 N E A 1 _ w t, 0011 CULT�G 7 + 4�et�_SE��{"tnN C F ,4/✓!$�p �9p�a �� e= ��`�'! �� ' 1 `' ,! ,t A- FLOOD INSURANCE NOT AVAILABLE FOR NEW CONSTRUCTION OR SUBSTANTIALLY IMPROlIED S*URCTURES O AND AFTER _._ ,m __._,.__,... ,.. ►. �• ' . ? •= NOVEMBER 16. 1990 IN DESIGNATED COASTAL BARRIERS. FF- [A> , 12' , � 4' 3 - - Sr- r AO PdL I . " ?d 3000 33.G �_ � .o � / ';�' �� �. � 3�tDER:!~G 32 G 4 ii A z- v L �4 FIELD �� vEt;E-AT>:!D SL w SeMG ti 'Ol �. o g•N D � WETL0 r/ \ 1 ® 1 A-1 > wo,w- tom=2t T O P O F \COASTAL E A. -- ti / --- -- \ic fo C1LEEA AR AREA Of t �IkIc-LS FAMIL:� C) mot TSI&a DATA - 1--/kF-SA0A t:'.FJtiR� AREA WITt-1 Ga¢r3AG.c G¢,��:e. No B�rz-o0445 DAI LY s=ww = 9 x I to =`t',, GPP 4 r-t7e7 1465 -- Sz7-nG TAN L qq -jh b 'F � < �-�" •azay °REAF \ >1 B- e- 8-2 grA LCCB FND l)5E 20 CuLTEC E�L�P1.�-��,-30G1�-A%+tiEsePs� SJ•p,Jt - � . �ij� / �� .� \ ' "�j• / - - S S _CONCRETE ( S - =2czS SF HEADWALL A SPHALT ,�ppL1GdT1DN L11z54 U�516.N 7E k ! ►.� � / / / ��j�✓ BERM �j'� is� 6� ESSPGncs TD�wt �� �j LCCB FND SIZ�wQLL AO---AS -lq `I.X1;--(r3ZSF $ F►t_C.C::;J w tTlt-� Llr Qhr� o LA,(—. gr�+' G F EL - 3.10' 0�Z Zola Ctd. Z 0 N E I / CB/DH ITID EL 7.37 I - O K E Y ELEVATIONS REFER TO NGVD REFERENCE M 28 QV MONUMENT FOUND 0 WOOD FENCE -- v o -•- � � / •� 'try S WATERGA'T P { / / .\ JULY 1997 WATERLINE w �' MEAN fi!GH wa.TER SITE P L A N GAS VALVE/METER M !/ GAS LINE 9 9 - / / AT UTILITY POLE/NUMBER -0-- z 0 N E A 1 1 421 SOUTH MAIN STREET UTILITY.TRENCH (BACKFILLED) ---ET-- - / ELECTRIC BOX/TRANSFORMER PAD 1E7 (E L 1 1) / OSTERVILLE, MASS. WATER METER BOX ELECTRIC MANHOLE ® / Z O N E V 1 6 FOR HYDRANT (E L 1 3) EDWARD ESKANDARIAN LIGHT POST \�: • STEEL/SEPTIC COVER QS STAKE FND EL s 3.85' SCALE: 1" = 40" JULY 23, 1997 HEDGE / REV►SEA QUlfo. 2oi 1991 L4bD_ EaoL t?1\ V-1 & SE-T1G' EDGE OF LAWN / 8812 MAN STREET APPLE TREE OSTERVILLE, MASS., 02655 PINE TREE (508)-428-9131 ELM TREE �P� i / =yam / ENSR WETLAND DELINEATION FLAG �< GRAPHIC SCALE 0-- 4 � F "{ 40 0 20 40 80 ISO A. TOPOGRAPHIC LOCATION DATES: JULY 10, 11, 14 do 17, 1997 UXTER A F0.2a�7333 FLOOD LINES DIGITIZED USING FIELD/TOWN CIS SHEET LOCATION OF IN FEET ) EXISTING BUILDINGS ON LOCUS AS ORIENTATION; TOWN GIS SHEETS 1 f f P�" r� /� 1 inch 40 fL ALLIGNED WITH FIRM COMMUNITY PANEL USING ROAD AND WATER LINES G .• V �l j�� 96172 (SITE01-DWG) ZONE: Mnd \ RF-1 & RPOD Area (min.) 87, 120 SF J°Sh ° Lce 43 cry Fron to e (min) 20' Pond o` n� \ Width (min) 125' Setbacks: szs \ \ Fron t 30' ,,e< Co,, Side 15 , DESIGN DATA Rear 15 LOCUS \ es T c SEPTIC NOTES or eo 'yD// Single Family-4 Bedrooms 1.Location of Utilities Shown on This Plan Are Approx.At Least 72 Hours i �s. \ C p/�s�Op/ No Garbage Grinder Prior to Any Excavation For Thia Project the Contractor Shall Make Oj - A� !`i ) Fs/ J Daily Flow=4 X 110 GPD=44o GPD the Required g ( _ ). 0 VERL A Y DISTRICT °c J� �'� / \� �s03 cz/ T�4s Use 1 Gallon 3epdc Tank o=880 Gallons 2.The Contractor ids Required to Secure lAppropn�ate Permits From Town °cc / ^"� "gyp x" �, / / �s 3.Agencies w�i s�beC teon Defined a Coordination With AP - Aquifer Protection District East Bay ads REMOVE EX f LEACHING AREA COMM Water,and shall be in Accordance With 248 CMR 1.00-7.00 As Shown on Plan Entitled os� T�APPIIT, +s'��� `T/?S� l 440GPD/0.74-595SFRequired &310 CMR 15•00. " "Revised Groundwater Protection Q * 3 ! 4.Install Risers with Cover to Within 6 of Finished Grade,or » '> f 390 t,�o Q R� �� F / Sidewall-202 +302-192SF Overlay Districts - Aril, 1993 ° � _& OLD PIT 2 ( / ( Bottom Area=(1 2'x 36)=432 SF to Pavement Finished Grade As Requrred(4 Required). y p 4 Dowses Zon r More or Subject 624 SF Total Provided 5 to Vehicular Trafficto 20.All Structures Buried Three Feet oLoading.It s the Engineer's Beach ea / a e C Recommendation that H-20 Always be Used. nc�A nt_ \ I 1 / vEnlr/ °' ��83 , Zoned' LEACHING CHAMBER DESIGN 3 \ co e (^ ro ��sr I 6.Septic System to be Installed in Accordance With 310 CMR 15.00& PROP D BOX tirO�t� 1x-1 J y��� /�� All Pipes to be Schedule 40. Use 248 CMR 1.00-7.00 Latest Revision and the Town of Barnstable FL 0 0 D ZONE: \ PROPO o oy. / / v`0 o yw \ 4-500 Gal.Leaching Chambers in a Board of Health Regulations. TH-4 ,/ / I 1 �, \ Opp, 1%5 12'x 36'Washed Stone Fields a Shown. 7.All Piping to be Sch.40 PVC. Zone C, B, A 13, & A 1 1 Locus J V I a p F � 8.Inlet Tees Shall Extend a Minimum of 10" Of,6121 Below the Flow Line. Community Panel No. Scale: 1"=2,000f' 1 txry o^f �� `(�\ 9.An Outlet Tee Shall Extend 14„Below the Flow Line, #250001 0016D `m ( 1 and Shall be Equiped With a Gas Baffle. July 2, 1992 ASSESSORS REF. : SEWAGE Vault `� Map 164, Parcel 004 1 97-469 cr;toVn �'? / ( VENr BE FIELOCADE ENRMINEn \ AsanWt Dryve C�c Puip \ N; X; ^ &Heater / SLAB E See Mote 4 (typ.) F.G. £1 43.0 J NOTE 7 (TrP.) 40.50 �;' Installer To C ��: L 0 T AREA Ufffiffes SEWAGE Pool & Patio Area \ Confirm Prior EL, OO f 97-469 To An Work Cl° 5.44±Acres lsoo coflan r / Transformer \ \ `\ y -20 75 EL H-20 Top EL 40.00 \ ,\ Septic Tank O-Box 33 ° Generator \ \ EL. Leaching \ '\ Flow g �Ir� Chonbev Bedding,'T-s & Boffels 10, Min. as Per rifle 5 ;»;•i....... • ....: u: �• ! ,\ - See Notes 8 & 9 :' :::c::;.:ic1"i ,y st. \ 10'Mir.. - Slab ;:..::• - :: ;� �- 20 Min. Foundation :7y"gHFjtf;F#rRet`;: :S, F ► ,y - Groundwater �"!/ :.................. ........ ........................................... Per 1H -2 C%-C/ Developed Profile Of Proposed Septic System Per r.°o a"�oundwater Maps o \ Not to Scale ! n'� \ \ Finish Grade OVV �o �O � p J.T Max. CB/DH r Q \ •\ 9 M4r Compacted f7/! Filter 'J Fnd Fabric -'00. And/Or 0 c'. 1/8" - 1/2" ���� Pea Stone xZS I Limit of BVW LEACHING oo ble washed" as flagged by ENSR 251JUN11997 CHAMBER Stone located by Baxter & Nye, Inc., JUL/97 41 10' I CB/OH e°��� R Q I \ \ f 12. Fnd / \ Cross Section Of Chamber Stone \ �n ��/ 8 0• Steps \ Not toScale PERC TEST: 12,488 Q PERFORMED BY:JOHN OD EA.Fd'T- SULLIVAN 1'.PIGINEIItiNG ��j OJ \ •\ SOIL EVALUATOR NO.2911 WIITTESSED BY:DONNA MIORANDI,R.S.-TOWN OF BARNSTABLE • v. MARCH 11,2009 \ \ / TEST HOLE- 1 I ::•«:::::.....Y:.Y:: :::. :::•J Y:::.:::EL.az.s TEST HOLE-2 EI.43.0 _..,...... _......__,:Y......_. _....._.. ��• � Fnd _.....«::::::.:J:::.Y......._. :.-.::. Y:«:::.:::•::: :•«Y: __...........-:Y. ' •_...:.`. ............... :::. .r.,::«W::::::... .. : •a..Y�.. _iY::.: :Y�r•:«= .:ss -��.ir=�•yrn} `,r,'_'•Y_Y::y. ayr•:^>^:•g:»y:a•,, ..:_..... .. ..... ..... -:..... 'x.:c?=.ii�i:,• ii:i. 401, �::::..._:.:.:+4:Y„ v 2'^"^i ^% ii: •'Y.(?is 38.5 5" 'T?: •"}7 •t :i "iYl•:.:a ..Y:.42.6 / ' :''''• _�:wr.Yxx;.:.x: °s::.•rni.•.i.'r.Y__: :.:i•iii�Wii:ix. ....1. . .......... ._....._.._.. ... ;tom .: .x:a'::�a«„;: `r Y ......ay....._r:.v:� 3/.S •: {�v. r;•Y•x"k•••Y. ::".Y;;/fe?:yi'r,:�-y.%a:�s'gii: p man CC \ i LCB 60" ::•••:> >> `t•:: ' 3 .:_. - . .. 41.9 serer ybn �, 98 / C1 LAYER lOYR 5/6: ~> i .N :,:,::: ::::::. ` 1 ......... Y r ._. / Fnd/ YELLOWISH BROWN x y ::.:•:Y.::.; .:::•:sic? ;�..... L� 3 3 \ �a••aq«,*.t[, iim. :~••• r"rL;n}�t{::i;:'t:4?: •roy� Fst / St / sa^ MED.SAND W!FEW Fu4Es 3s.s 2a":` :-rr`• tw:-J :;•:~-•..:::YY.::J ai.o C2 LAYER IOYR G6 C I LAYER 1 OYR S!6 C/f/¢3�! f 7 T/Zrs� ��e+ �, ^ BROWNISH YELLOW YELLOWISH BROWN 120 MED SAND 32.5 Q. MED.SAND W/FEW FINES 7 SJ 4s/ee v Im >> �`O\v / Existing Pier NO GROUNDWATER ENCOUNTERED C2 LAYER 10YR 6/6 Q '� �,� �� / BROWNISH YELLOW N IN lA D \ MED SAND / 44^ PER TEST 39. 25 GALLONS IN 8.5 MIN. / 56" <2 MINAN. 38.3 TEST HOLE-3 C3 LAYER 2.5Y 6/6 1 / EL.43.0 OLIVE YELLOW 2y >:: 132" MED. :i;;« 32.0 i v _»<ti_;.if«ii �1/• ":«J.�S.;,,".:.Kw • - ... NO GROUNDWATER ENCOUNTERED .....Z:Y.YS t, •N SY««AY.;Y.-:. eo TEST HOLE-4 /' �ot ' V) = ` : "=: 42.0 1 L.42.5 ••�i M : „ "r..;,vyic: '• ^i._.t•••:: •:»x:;rxiitiii:i ..••.tis:$:riiiiiii�'r'i$i'ir•'r ?O"Zoo ('Sr92 �H OFir{` ^;-r "z'::c.. 1 ^r' ?.i _.... :•&.............. z?''iiiii» 9 / of tJ � ti' :-:.x:n-:�:;:i�<:.. 9 c G i^ _.. , .. C Ya:t:Y^y.^ :tAA` :::J:'RT:::•::'.7^ �•:t C'•. .. T i•:•: 24 'ia«it::-•.i•.:•Y:i:� '' � G',4a ^rFi .:x'S'i....:......... �r/Lo�e'rl�y 8¢`3 � J l JOHNAC• s _. ._ .CI LAYER IOYR5/6 41.0 SO ...s•:-CY,:�t:..Mr: W.Y :w....,..t.,� ..}5.r1'.....36.3 OTC .Z 4•::.„Y t ___�/NC ..:. L'/jr'39 TQ//y Tr 1 o CIVIL SHBROWN 48168 ME $D. AND�W/FEW FINES 61""":�i~`ti•;-�{-r :.'. ...i r.::-Y rr rn 37.4 Edge of Coastal Beach No. 30" PER•EST 40. _ C1 LAYER IOYR 5/6 6 e as flagged by ENSR 25/JUN/1997 09 9FGl STEP�`� ��� 25 GALLONS IN 8.5 MIN. YELLOWISH BROWN CB/DH j FndGBH, located by Baxter & Nye, Inc., JUL/97 �FFSSIONAL�N�\� 42" ���I OYR�6 39s 8 " 1 SAlDwi��F1NES 35A ' eo BROWNISH YELLOW BROWNISH YELLOW / My� Mean High Water 54" MED SAND 38s 120" MED SAND 32.5 as Located 161NOV100 C3 LAYER 2.5Y6/6 NO GROUNDWATER ENCOUNTERED EI=1.8' NGVD '29 OLIVE YELLOW 120" MED.SAND 33.0 NO GROUNDWATER ENCOUNTERED NOTES: 1.) The property line information shown was PREPARED FOR: PREPARED BY.• TITLE: compiled from available record information. Site Plan 2.) The topographictheiound survey �s obtained Edward & Nancy ESkondarian Sullivan Engineering Inc. CapeSury Proposed Improvements from an on the round surve performed on- 1 or-between 151NOV & 18/NOV/00. 300 Boylston Street, #806 PO Box 659 7 Parker Road w t Boston, i�l/lA. 02116 Osterville, MA 02655 Osterville MA 02655 H J.) FEMA Zones Lines were compiled from Town O of Barnstable G.I.S. & current FIRM. (508)428-3344 (508)428-3115 fax (508) 420-3994 (508) 420-3995 fax 421 Main Street copesurvOcapecod.net 4.) The Contours shown were taken from Town of Barnstable G.I.S. Barnstable (Osterville) Mass. Draft: Field: RRL 40 p 20 40 80 160 JOD WHK� � 5.) The datum used is NGVD '29, a fixed mean Review: PS Comp.: RRL DATE: March 11 y 2009 SCALE: , r1 _401 cn sea level datum. B.M. assumed. Project # 97012 Project # C455