HomeMy WebLinkAbout0424 MAIN STREET (OST.) - Health � c
424 Main Street
O.sterville
A= 164'.- 002 .
1
a Commonwealth of Massachusetts "� ��
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
424 MAIN ST
Property Address
MCNULTY -
Owner Owner's Name _
information is LLE MA, 10-12-14 '
required for OSTERVI '
every page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
n I m
forms on the ,1' -
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector .
use the return
key. DOUGLAS A BROWN INC
Company Name
P.O. BOX 145 . . .
Company Address-
CENTERVILLE MA 02632
City/Town- State - Zip Code
508-420-4534 s' S14297,
'Telephone Number License Number
B. Certification ;
I certify that I have personally inspecte�the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ;❑ Fails y _
❑ Needs Further Evaluation by the Local Approving Authority ` r
10-12-14
Mejoars 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 is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to•the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent•to the buyer,..if applicable, and the approving authority.
*""*This report only des ri §:conditions at the time of inspection and under the conditions of use
at that time.This.inspect on,does nott`•address howA a system will perform in the future under r
" the same or different con,4i ons:ofi'use.F;. .
t5ins-3/13 Title 5 Official Inspection Fc : surface Sewage Disposal System;'Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official. Inspection Form, `a
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 424 MAI N ST
Property Address
MCNULTY ;
Owner Owner's Name
information is required for OSTERVILLE MA ..10-12-14
every page. City/Town State Zip Code Date of Inspection
B. Certification cont.
Inspection Summary: Check A B,C,D or E/always complete all of Section D
A) System Passes: _
Z. 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. r`
-Comrrrents;
CHAMBERS ARE 1N DRIVE WAY,AND ARE H-20 WITH METAL COVERS TO GRADE TANK IS IN
LAWN AREA AND IS NOT H-20: -
B) System Conditionally Passes: ;
❑ Ore 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
r 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): . 4
t5ins•3/13'' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 '
Commonwealth of Massachusetts
Title 5 Official Inspectionform -
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 424 MAIN ST
Property Address
MCNULTY
Owner Owners Name .
information is required for OSTERVILLE MA 10-12-14.
_ - -
every page. City/Town State Zip Code Date of Inspection'
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired. . ,
B), System Conditionally Passes(cont.): '
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will-
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ,
_ ❑ t obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):..
❑ The system required pumping more than 4 times a year due to broken'or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑.Y " ❑ N' ❑ ND(Explain,below):
❑ obstruction is removed ❑ ,Y . ❑ N ❑ ND (Explain below).-
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the'system is failing to protect public health, safety or the environment. ,
1. System will pass unless Board of Health determines in accordance witli 390 CMR .
i 15.303(1)(b)that the system is not functioning in'a manner which will protect public health,
safety and the environment: t
❑ Cesspool or privy is within 50 feet of a surface water
V ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments ,t
424 MAIN ST d `
Property Address
MCNULTY
Owner Owner's Name
information is required for OSTERVILLE - MA 10-12-14
` - - ,
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.) F R
2. System will fail unless the Board of Health (and Public Water Supplier, if any) ,
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑,The system has a septic tank and soil absorption system (SAS)and the.,SAS is within
-100 feet of a surface water supply or tributary to a surface water supply: .,
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply. r
❑"The system has aseptic tank and SAS and the SAS is within 50 feet of a private water
supply well. r ,
❑ 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 forma
3. Other:
s c +
D) System Failure Criteria.Applicable to All Systems:
You must indicate"Yes or"No"to each of the following for all inspections:
' Yes 'No '
Backup of sewage into facility or system component due to overloaded or
❑ ®, ' clogged SAS or cess ool,
� r 99 p t
F' Discharge or ponding of effluent to the surface of the ground or surface waters
® due to an overloaded or clogged SAS or cesspool
❑. ® Static liquid level in the distribution box above outlet invert due to an overloaded'
A or clogged SAS or cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less
P El , ® than 1/ day flow .
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 17
Commonwealth of Massachusetts y"
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM '` 424 MAIN ST ,
Property Address _
MCNULTY ; tt
Owner Owner's Name
information is required for OSTERVILLE '� MA 10-12-14� `
every page. Cityrrown Stater Zip Code -Date of Inspection
B. Certification (cont.) ,
Yes No
❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or
r
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: ` 'y
❑ ® Any portion of a cesspool or privy,is within a Zone 1 of a•public well.
- ❑ ®; Any portion of a cesspool or privy is.within 50 feet of a private water supply well.
❑ ®, Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptabie 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
it ,-,of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A coo the analysis
and chain of custody.must be attached to this form.]
The system is a cesspool serving a facility with a,design flow of 2000gpd-
10,000gpd. s ,.
❑ ❑-. The system fails. I have determined that one or more of the above failure:, ,
71 criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) `Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd. {
For large systems, you must indicate either"yes"or"no"Tto each of the following, in addition,to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water`supply Y
the system is within 200 feet of a tributary to a surface drinking water supply
j ❑ the system,is.located in a nitrogen sensitive area (Interim Wellhead Protection
Area 7 IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered'a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade-the
system in accordance with 310 CMR 15.304. The system owner should-contact the appropriate '••
regional,office of the Department.
t5ins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System;Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
424 MAIN ST
Property Address
MCNULTY
Owner Owner's Name �•
information is required for OSTERVILLE MA 10-12-14
every page. CitylTown State Zip Code Date of Inspection,.
C. Checklist e
Check if the following have been done.,You must indicate"yes" or"no"as to each of the following:
^� Yes . No • ,. ` . r- � �f :! '_• I
❑, ® 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?
® El: - Has the system received normal flows in the previouEl
s two week period?
Have large volumes of water been introduced to the system recently or as part of®
c this inspection?
{ Were as built plans of the system obtained and examined?(If they were not
t
® El' available note as N/A),
t a ® ❑ r, 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
ti 0 , ® 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:
t ® ❑ • Existing information. For example, a plan at the Board'of Health.
k Determined in the field (if any of the failure criteria related to Part C is atissue
❑ ® approximation of,distance is unacceptable).[310 CMR 15.302(5)] .
' D. System Information
'Residential Flow Conditions: '
Number of•bedrooms(design): 3. Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR'15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Forme
Subsurface Sewage Disposal System Form --Not for Voluntary Assessments
M ,a 424 MAIN ST
Property Address
MCNULTY
Owner Owner's Name
information is OSTERVILLE MA P 10-12-14
required for
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description: '
SYSTEM CONSISTS OF A 1000 GALLON TANK D-BOX AND 2 H-20 500 GALLON CAHMBERS AS
PER AS'BUILT
Number of current residents: _ 1'
Does residence have a garbage grinder?' ` ❑ Yes ❑ No
�. Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑.Yes ❑ No
Laundry system inspected? k ' ❑. Yes ❑
No
Seasonal use? 5 '❑ Yes ❑` No'
Water ineter'readings, if available(last 2 years usage(gpd)): .
Detail
2012----197 2013------208GPD
} Sump pump? r _, ❑ Yes ❑ No
Last date of occupancy: -
Date
Commercial/Industrial Flow Conditions: -
Type of Establishment.
Design flow(based on 310'CMR'15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap preserit?.. , „ ❑ -Yes ❑ .No
Industrial waste holding tank present?_ ❑ Yes ❑ No
�.
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
F Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
r
Commonwealth of Massachusetts II
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,
M , 424 MAIN ST
Property Address
MCNULTY
Owner Owner's Name
information is OSTERVILLE MA f 10-12-14
required for t '
every page. City/Town i` State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: , pate
Other(describe below):,
General Information ,
Pumping Records: '
Source of information:
Was system pumped as"part of the'inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping '
Type of System:
® !Septic•tank, distribution box, soil absorption system
❑ r a` Single cesspool
r Overflow cesspool
- Privy_ 4
❑ { Shared system or no) (if yes, attach previous inspection records, if any) ".
❑ Innovative/Alternative technology. Attach a copy ofthe current operation and
maintenance contract(to be obtained from system owner)and,a copy of latest
t inspection of the I/A system by system operator under,contract
❑ = Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
424 MAIN ST
Property Address
MCNULTY w r
Owner Owners Name
information is required for OSTERVILLE MA 10-12-14
every page. Cityrrown State. Zip Code D2te,of Inspection
D. System Information (cont.)!
Approximate age of all components, date installed (if known)and source "f irif6ftatio" .,
LEACHING SYSTEM 2007 PER AS-BUILT
Were sewage odors detected when arriving at the site? C1 Yes (` No .
Building Sewer(locate on site plan):
De th below rade:
- P 9 .. 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.): ~
Septic Tank(locate on site plan): ,.
Depth below grade: feet
Material of construction:
® concrete ❑ metal -❑fiberglass ❑ polyethylene ❑ other,(expla in),
If tank is metal, list age:
years
'Is age confirmed by a Certificato bf Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 GALLON
.Sludge depth: LIGHT
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•
424 MAIN ST
GM .
Property Address °
MCNULTY .
Owner Owners Name
information is required for OSTERVIILLE MA "10-12-14
'
every'page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.) '.
Distance from top of sludge to bottom of outlet tee or baffle
.Scum thickness LIGHT
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to"bottom of outlet tee or baffle
'How were dimensions determined?` r WOODEN POLE
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 LOOKED FINE AT TIME OF INSPECTION
d
Grease Trap (locate on site plan);
.'Depth below grade`. Y 4` feet
Material of construction:
❑ concrete a ❑ metal' ❑fiberglass ❑ polyethylene � ❑ other(explain):
Dimensions:
yScum thickness x •f ' -
Distance.from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of+last pumping: ° Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System°Page 10 of 17
Commonwealth of Massachusetts `
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t
M 424 MAIN ST ' `-
Property Address
MCNULTY ,
Owner Owner's Name
information is required for OSTERVILLE MA 10-12-14
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) -
Comments (on pumping recommendations, inlet and outlet tee or baffle condition; structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
' n k ;t
❑concrete ❑ metal'. '❑fiberglass' ❑ polyethylene ❑ other(explain):'
Dimensions:
Capacity: '
, gallons., '
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ •No'
Alarm level: Alarm in'working order: _ ❑ Yes ❑ No "
Date of,last pumping. Date
Comments(condition of alarm'and float switches, etc.):
' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes` ❑ No ; '
t5ins•3/13 k Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
424 MAIN ST
Property Address _
MCNULTY
Owner Owner's Name am
information is required for OSTERVILLE MA ' 10-12-14
every page. City/Town State Zip Code Date of Inspection
D. System Information (cost)
Distribution Box(if present must be opened) (locate on site plan):,
O„
Depth of liquid level above outlet invert
Comrrents(note if box is level and distribution to outlets equal,any evidence of solids carryover, any:
evidence of leakage into or out of box, etc.):
BOX LEVEL NO LEAKAGE OR SOLID CARRY OVER'
Pump Chamber(locate on site plan): "• ,
Pumps.in working order: E ❑ .Yes ❑ No"
Alarms in working order: y El 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.,
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located; explain why:
'1
I
t5ins`3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System`Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 424 MAIN ST
Property Address '
MCNULTY.
Owner Owner's Name
information is required for OSTERVILLE MA 10-12-14
every page. City1rown w State. ` Zip Code Date of Inspection
D. System Information (cont.); -
Type: +.
❑ ; leaching pits number: -
® r leaching chambers' number._ 2•
El leaching galleries number: ,
�w.
❑ leaching trenches number, length:
El leaching fields -4 number, dimensions:
overflow cesspool ' ry number' -
El innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil;condition of
vegetation, etc.):
SYSTEM HAS 2 H-20 500 GALLON CHAMBERS ONE HAD ONLY DAMP'SOILS AND THE OTHER
HAD ABOUT 6" OF LIQUID AT TIME OF INSPECTION
Cesspools(cesspool,must be pumped as part of inspection) (locate on site plan):
Number and'configuration
r Depth �:top of liquid to inlet invert
Depth of solids layer
- Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ ,Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection form .,
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
3
M 424 MAIN ST. -
5
Property Address
MCNULTY
Owner Owner's Name
information is required for OSTERVILLE MA t ' :1.0-12-14
every page. Cityrrown State , r Zip Code Date of Inspection
D. System Information (cont.) .
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Deptti of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): ,.
. t5ins•3/13' Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 `
F '
Commonwealth of Massachusetts
Title 5 Official Inspection Form a.•
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
424 MAI N'.ST
Property Address
MCNULTIr`
Owner Owner's Name
information is required for OSTERVIiLLE '•MA 10-12-14
_
every page. Cityrrown State Zip Code Date of Inspection
D. System, Information (cont.)
Sketch Of Sewage Disposal System: Provide aview'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
® drawling attached separately '
.• � ..�"' •W - 'is ,.• t r
21
W
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17'
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
G M , 424 MAI N'ST • - ' • - -
Property Address
MCNULTY"
Owner Owner's Name
information is OSTERVILLE MA 10-12-14
required for '
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont:) ,, H
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells =.
Estimated;depth to high ground water: GREATER THAN 5;'
feet
Please indicate all methods used,to determine the high ground water elevation:°
® - Obtained from system design plans on record
If checked, date of design plan"reviewed: SEPT 2014 ';" •`
Date _
❑ Observed site (abutting property/observation hole within.150,feet of SAS)
❑ Checked with local Board of Health-explain: A
• i
❑ Checked with local excavators,-installers-(attach documentation)
❑ " Accessed USGS database-explain
You must describe how you established the high ground water elevation:
Before filingthis Inspection Report, lease see R Completeness C k's e ort hec list on next�page.
• .
P P � p PP 9
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17,
Commonwealth of Massachusetts- ,
. Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System`Form-Not for Voluntary Assessments
G M ' 424 MAIN'ST _ w , •;.fix-- ♦
Property Address r
MCNULT'Y t
Owner Owner's Name
information is required for OSTERVILLE 3 MA` 10.12-14
every page. City/Town State Zip Code Date.of Inspection
E. Report Completeness Checklist .
® Inspection Summary:A, B, C, D,or E checked
® Inspection Summary D (System Failure CriteriaApplicable to All Systems)completed
® System Information-Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page'15 or attached in separate file
_ - - ' a J♦
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Assessing As-Built Cards Page 1 of 2
TOWN OF BARNSTABLE LOCATION ewcUn S P SEWAGE#! 39 y_U-)
VILLAGE o 51wut1l C ASSESSOR'S MAP&PARCEL ho kf -U
INSTALLERS NAME&PHONE NO. 44_w tAke CA V- '(ak yU a k' 4
SEPTICTANKCAPACITY
LEACHING FACILITY:(type) a SOu Lc It Zv(size) NZ Y
NO.OF BEDROOMS 3
OWNER IM,o.r j` L:1 h Q4►Q t'�
PERMIT DATE: -7 •?O? COMPLIANCE DATE: q'.1 N Z 001
' 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 erX ie.- >es. L L c
as g p
Al
C44 If.., w• % '
0,5 gam. S C
A
0.
http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=164002&seq=1 10/12/2014
i � I
TOWN OF BARNSTABLE CS®���q LOCATION �Jo?Y ry �n S SEWAGE#
SVILLAGE 0,5 ASSESSOR'S MAP&PARCEL Ap 1L( -U 1
INSTALLERS NAME&PHONE NO. vak4 yu a�!
SEPTIC TANK CAPACITY 1000 a c- L� o
LEACHING FACILITY:(type) (42) Too I,4 l-r ao (size)
NO.OF,BEDROOMS 3
OWNER 1M.o-r j
PERMIT DATE: Zoo-7 COMPLIANCE DATE: - i L'I Zoo-,
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY e.4 �"Yl t/ ✓��GS L L e
f
p
A a �`�• 3
� 1 It. o
�S 3�
� r
p No. .000 Fee
V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZippYicatton for ]h5pont *p!tem Conotructton Vermtt
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) ❑.Complete System ❑Individual Components
Location Address or Lot No. Gil"( MR;. S jY"e-T, Owner's Name,Address,and Tel.No. 1460 reaw
pebrcv,4j� e 42N Sf
Assessor's Map/Parcel a 0S mevq t< OWA
Al ew,1�+2 ^t
Installer's Name,Address,and Tel.No. P Designer's Name,Address and Tel.No. ':fir✓el) k
� � azg� zssyc2a►., �`'Y
Type of Building:
Dwelling No.of Bedrooms Lot Size ��3 a J�® sq.ft. Garbage Grinder ( )
Other Type of Building S; No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3`3 gpd Design flow provided 3 1 gpd
Plan Date CA-$' ->?o'� Number of sheets Revision Date
Title /fah S 1'
Size of Septic Tank //^^ ��((�o n Type of S.A.S.Q--) N'2,a Sot, 94C (_(< Ste
Description of Soil
Nature of Repairs or Alterations Answer when applicable) &0-.4,je-
L SJVV
X t �� )t►��
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 this Board of Health.
Signed Date 01 C
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. �-d y l —'� T Date Issued
`` No. .goo � % \ �--•�`� Fee 1� v
QJ i
—THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Application for �Dtgonl *patent Con0truction Permit ,
Application for a Permit to Construct O Repair O Upgradel 4 Abandon O ❑.Complete System ❑Individual Components
Location Address or Lot No. Lp L q me:- $Tlf e'Q T Owner's Name,Address,and Tel.No.
O b i EYt-v:�l e �2`I rit3,ti 5 i
Assessor's Map/Parcel '(e i.r
C 14 .�Q F,y 1 t!{J Y'� .
SG ls. ►).she �j"4
Installer's Name,Address,and Tel.No. P Designer's Name,Address and Tel.No S ,.,,
i '71-3 ZFS4 C2Av.(o t, I41wy
S 6 '41A `1�L S �.�irt}U�.l� h 570? a-7 3 a 3-7) C,w Ar,-(W `, r
Type of Building: ,,.
3 Dwelling No.o'Bedrooms f Lot Size �� r sq.ft. Garbage Grinder( )
' Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) '3 3-o gpd Design flow provided 3 • _ gpd
gP
Plan Date c1-5 ' 2 00 I Number of sheets ( Revision Date
Title 4L`l ry"h 5
Size of Septic Tank (V O a ii Type of S.A.S.Q Z) 0 -40 $70 0 9 A L L,,C• Wj$%&'4 t'
Description of Soil Q 4►41n �` f.l l Q �(Q r '"
Nature of Repairs or Alterations Answer when applicable) nQ,o%) `i Q� ,�2 �C�O �t. `-• C
I `
Date last inspected:
7
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisio.-is of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued:)y this Board of Health.
Signed Date "' (0
Application Approved by Date ( ` 7 —0
Application Disapproved by: Date
for the following reasons
Permit No. Date Issued V
` THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded
Abandoned( )byi>►
at T Tjd 05 TEA,U t l I C has been constructed in accordance
with the provisions of Titleg5 and the for Disposal System Construction Permit No. 2,00 "Y)q dated "'-7 -0 7-
Installer �AeCA4', 1_nf-a 0ri 5, S Designer 'S,C,
#bedrooms 3+ Approved design flow J� gpd
The issuance of this t shsl not construed as a guarantee that the syste will fun f de 'gned.
Date 01/ Inspecto w.
——————————(
No. �0 � ————————————————————————————M0--———
� r 1 Fee 1y
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS
1111i5po5al *p5tem Construction Permit
Permission is hereby grantej to Construct ( ) Repair ( ) Upgrade (OC_ Abandon ( )
System located at -Lrq (44A,, ST(-CA.;t Q 5-r)E VLvt 4,L
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and tae following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
12
Date d �`' Approved by _] 12
x
SEP-24-2007 09 :24 AM JCENi-INEE'RING 508 273 0367 P. 01
Town of Barnsi.ame
Regulatory Services
Thomas P. Ceiler,Director
t►toy Public Health Division,
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Offita; SOR-862-4644 Fax; 308-790-6304
Installer &_Designer Certificatign Forth
q/ � Q
Date:
i
Designer; L, 6�Vdl�1/ �i�Ji✓G. IN _ .�. P
Installer: G1°�e•�l T ,e�St S
Address: Address: 6
CWT
On I� Q G�yPWsi. _ ek , s<�' was issued a permit to install'a
(date) (installer)
septic system at S r based on a design drawn by
(address)
2 � ...;,L .,�. dated_ .�,...,.�.�.. ��•
(designer)
I certify that the septic system referenced above was installed Substantially aecordin to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank:
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic'system) but in accordance with State & Local Regulations. Plan revision or .
certified as-built by designer to fallow.
or
JOHN L
CHURCm&L o
JFL
(In a T er's Signat v �ieoy
4 eer's S3 afore) (A �x Desi er's Stamp Here)
Pf-,� SiPRETURN 'O BARNS'i'ABLE P BLIC REALTH DIV N. C E TIi�'IC,�,„ F_.
F COMPLIANCE WHJI NOT BE-ISSUED UNTMI BOTH THh FO , D AS-
BUILT CARD ARE BECEIVLD BY THE BARNSTABIS, PUB1 IC HE A I-TH DIVISI .
THAN OU. F
Q:Health/Septic(Designer Certification'Form
q Je 4S 220- klic aratlon of 3'lans and ,, eci 3,Y i» T7 u r , r •. .-ate ��r ,n- - r r -
Tnd plan.; and specifcaddns -for'every on-site system shall be prepared..hs follows:
(1) -Every system shall be designed by a Massachusetts Registered Professional Engineer
or a Massacl:-usetts Registered Sanitarian provided that such Sanitarian shall not design a.
gallons per day ursuant to 310 CMR 15.203.
system desigred to discharge more han 2,� B P Y P
Any other of the owncrjnay prepare-plans for the repair of a system.designed to
discharge not more.than than 2,000 gallons per day pursuant to 310 CMR IS_203 provided
they are reviewed by.'a Massachusetts Registered Sanitarian and•approvcd by the approving
� . aut:zority;.
(2). .Every:plan submitted for approval must be dated and bear thestam p and signature of
the designer,
(3J Every plan for a new system or plan for the upgrade or expansion of air existirig'systcm.
which requires. a,variance to a property line setback..distance, must:alsn rcfrsettec'a Ellin
which bears vie stamp and signature of a Massacltasctts- Licensed Land Surveyor in
accordance wigs M.V.L. c; 1I2,
(4) Every plan for a System sfia11 be of suitable scale 7(one inch=40 feet or fewer for plot
/an and one inch•=Z0 feet or fewer for details of system r;antpcnen4). 4..6d shall include. :
V non of:
) the legal boundaries of the facility to be served: _
the holler and location of any easements appurtenant to or which could impact the - -
stem;
(c) the location of rite ill dwellings) or buildizg(s)existing and proposed on the facility
d identeatiari of tzose'"to'be served by the system; - -
c1 a n� dsiv-was and
d) '=the''iirearion of existing or proposed irnperltious areas; in u. .x.o.-.. -_ y
p king areas _
location anddimersions of the system (including reserve area
system iiesign calculations, iricIading design daily sewage flow, septic tank capacity
ti o r. sy
stem capacity required and rovidcd); and --
vidcd soil absorption Y P Y P
re Hired and ro rP
� P )• _
a e Andcr
• 's dcsi oncd for arb g �' ,
• ether system*i a g •
(g) North arrow and existing and proposed contours;
(h).•,.location'and'log of deep'observation hole tests including the data of test, existin,
c elevations marked on each test, and the nairtcs of the representative of the :
a rovtng ajtl•.orty and soil evaluator;
i) location and results of percolation tests including the ante of test and tha names of
xfte representative of the approving authority and sail evaluator, .
�} dame and cctificatian number-of the Soil Evaluator of record.
(k) location .of ever}Vater supply,public and private,
1. within 400 feet of the proposca system location is the case of surface warcr
supplier artd gravel packed public water supply wells,
2. within 250 fact of the proposed systcm location in the case;of tubular public
water supply wells, and
3. within 130 feet•of the proposed system.location id the case of private water
Y supply wells.
1) location of any smface waters of the CCmmonwealth;•rivers, bordering.-vegetated
wetlands, salt marshes, inland or coastal banks, regulatory fioodway, vslocizy zone, :
surface water supplies, tributaries to surface watts supgIias,certified vernal pools,private
water supplies 3r•suctiait lines, gravel picked or tubular public water Supply wells, ' ..
subsuzface drains, leaching catch basins, or dry wells; and the location of any nitrogen
sensitive area identified'in 310 CNS 1$.215 wirb:L-t which portions of the proposed
I�/ 'stern taro locat:d.
m) location of water lines and-orhdr subsurface-utilities ort the-facility;
obserycd and adjusted groiutd=water elevation in the vicinity of the system;
o) a complete pzofle of the system;
(p) •a note on the plan listing 31I variances to the provisions of 310 CMR 15.000 sought
00_in cnjunction w.rh the pr1ar.;
q) . the location and,elevation of one bench=ark.within 50 to 7S feet of the facility
which is not siabj:ct to d%slocadon or loss.4-i Erng construction'on:the facility;
(r) when dosing is'pruposed, complete design--anti"specification of the.dosing system
proposed including.bnt not limited to dosing chamber capacity (required and:provided),'
urtp curves and specifications, number A1. dosi�$ cy:Ies and depth per cycle;
n/ ) whets a Rccirculat S Sand Filter or:quivalert alternative teehrtology is required or
V p posod, a complete plan and specification for the system,including a hydraulic proflc;
a locus plan,to show t<`te location of the I'aciliy including the nearest existing street;
KCthe street num'bet and lot number, if any, of the facility. and.
ifications of the system.
the materials of construct.oa.and.the spec
Town of Barnstable P#
lime Department of Regulatory Services
Public Health Division Date mv
euea..
200 Main Street,Hyannis MA 02601
Date Scheduled Time Fee Pd.
Soil Suitability Assessment_for Sewage Disposal
Performed By: 1'Itd0e t C, P,"Y1e:.1 Witnessed By: DooinA
LOCATION & GENERAL INFORMATION
Location Address y2 q Ma Owner's Name 411r<.e (help (4`f/
` �� S,✓•eeT
jj
e 5TE2�, kle Address 924 �OWI 3 E, 65te,UNA .
Assessor's Map/Parcel: `(p y/p®� Engineer's Name �•C.c r1S ytee ri c�
NEW CONSTRUCTION REPAIR ✓ Telephone#
Land Use Slopes(46) 2 s Surface Stones
Distances from: Open Water Body 7 100 ft Possible Wet Area 00 ft Drinking Water Well NIA ff
Drainage Way ft Property Line % 10 ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
See_ elvn clu�er� s�Ee.r►be: 5 t Zcro7
9
N
i
Parent material(geologic) C:AWc<Stn Depth to Bedrock 7 t3ti b5S
Depth to Groundwater. Standing Water in Hole: 7 t 3 y 1i bg 9 Weeping from Pit.Face
Estimated Seasonal High Groundwater 7 i
i
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: Dtteck 6o5eruc-•lton f 3 5/
Depth Observed standing in obs.hole: 7 I3 Y _ _ in. Depth to sail mottles: in.
Depth to weeping from side of obs.hole: 7 13 It F in. Groundwater Adjustment — fc.
Index Well# — Reading Date: Index Well level_,,:m,.�, A41.factor Adj.droundwater Level,,,
PERCOLATION TEST Data b-27-a7-a7 Thne / OV AM
Observation
Hole# I Z Time at 9"
Depth of Perc -�� Time at 6"
Start Pre-soak Time @ 11 it H 9 ime(9"•6")
End Pre-soak
Rate Min./Inchlu
Site Suitability Assessment: Site Passed /25 Site Failed: Additional Testing Needed(YIN)
Original: Public Health Division Observation Hole Data To Be Completed on Back -----
***If percolation test is to be conducted within 100'of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTICIPERCFORM.DOC
vYY
DEEP OBSERVATION HOLE LOG Hole# i
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency, Gravel)
6- 20
2.0-22 A L S 10Vr 312
22-- S 10 VE sl e -
AID--5 o C--( F-S 2, 5 g Y
06 C-2 HS 2. 5 b/d - LaCSe
DEEP OBSERVATION HOLE LOG Hole# z
Depth from Soil Horizon Soil Texture Soil Color Soil " � , Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel
Rd
` r2
2,0 2 V A L.5 Yr �
22-y0 93LS JOY( Sib -
yo-50 G-( t=5 2.5 '-1Y - —
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistenc o Gravel)-
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Qra 1
F
Flood Insurance Rate May:
{ Above 500 year flood boundary No_ Yes
Within 500 year boundary No '� Yes y
r Within 100 year flood boundary No �! Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist,in all areas observed throughout the
L--� area proposed for the soil absorption system? xz5
(lu If not,-what is the depth of naturally occurring pervious material? .
'Certification
I certify that on 00k (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required training,expertise an xperience described in 310 CMR 15.017.
Signature Date
Q:ISFPTICIPERCFORM.DOC
TOWN OF BARNSTABLE
LOICATION �pt� (ACL.N-V,.✓ 'S',-T SEWAGE # j
VIL,i AGE ASSESSOR'S MAP & LOT Opp''
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY I ()-Zr !? AI�v�
LEACHING FACILITY:(type) \=-*vkntra6k''T1+RS (size)
NO. OF BEDROOMS _PRIVATE WELL OR UBLIC-WA
�
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
.:
.,
\ �s��
�s,�.�� �
���' ° �
t ,p�
'V
�.
�,3�i w�-'`Ifir� s
ASSESSORS MAP N0:
PARCEL NO: �I
THE COMMONWEALTH OF MASSACHUSETTS
APPROVED BOAR® OF HEALTH �
TOWN OF BARNSTABLE
i t V u i i orko Cnouidra.rttun Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( L4"an Individual Sewage Disposal
System at
ft—
,ram -Location&Add or Lot No.
..........•. v` ...... ..................... ................. PT►......Vic•.........................................................
..
Ow z_ Add qe
Installer Address
UType of Building Size Lot............................Sq. feet
t--� Dwelling—No. of Bedrooms..... __.................................Expansion Attic ( ) Garbage Grinder ( )
'q Other—Type T e of Building No. of ersons____________________________ Showers
Pa YP g ------•--------------------• P ( )--- Cafeteria ( )
dOther xtures --- ----------------------------------•-••--••-•-•-------••---------•--...--•-••---••-......--•..__.. ......__..
Design Flow_______ ___ ________________________gallons per person per day. Total daily flow...._3.�d______._.___.___.______gallons.
W g ....
Length
Disposal Trench—No. _xk-�1 Width....1__0_....... Total Length.....tli_..____ Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.......................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................
a --------------------------------------------------••---------------••-••......•-••-----------_------........................................................
0 Description of Soil...............................................................................------------------------------------•-----------------------------------..............__.
U •••---••••---•-•••••••-•--•--•-••----•-----•-••--------••-•-•••---•••----•--•-••-•-------------•--•---••--•-••------•••----••-•--••--•-----••--------••••-••-•--•••-••••-•-•-•-•-------••-•--•••-----•-.
UW --•-••••--• ----------------•-•-•••-----------••••---••-•-•---------•--•-•------------••-•••••--•••----••-----•.....----------.........-•-----•---••-•--•--------••--•--------••-............--•---....
Nature of Repairs or Alterations—Answer when applicable.___�_64,STA�i�.._...(__� _5tronV z-:_`r��"-12
.Y........... -. ,�u--, �_1_ E' -r "' _T --•------------------------------------------------
Agreement: f
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been Vsued.by the board o ealth.
necDate
Application Approved By .. .. ............ ................................ ....
L�
Date
c
Application-Disapproved for the following reasons- ------------------------------------------------------------ - ...............................................................------
----------: ;------------------------------------------------------------------------------------- - ---------- -------------------------------------------------------------------------- ............................--------
i Date
PermitNo. ....) ................................................... Issued -------- �^ -t,� -��,------
Date
No. .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �
TOWN OF BARNSTABLE
/7 A -jg _9�2_
P-11'7Appliration for Elispoml Works Tonutrurtiun rrutit •
Application is hereby made for a Permit to Construct ( ) or Repair ( U-)"an Individual Sewage Disposal
System at:
................_.-�- — .... P�
- ---- ...............................................
Location dgs or Lot No0 .
.................
l
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms-_--- ---------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type-of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther xttures ------------------------------------------------------•----------------------•-----------------------•---------------------•---•--------.............
W Design Flow.......�..]�i........................gallons per person per day. Total fly flow---- --2_0...............__..._..galIons.
WSeptic Tank y Liquid ca acity.`. ._._. allons Length.... ,ir..._.._.. Width.-�.t____..... Diameter................ Depth................
x Disposal Trench—No. SkK td Width....I...(D ..... 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 Test Pit.................... Depth to ground water........................
f14 Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................
R+ ---•----•---------------------------------------••---------•---....-----................'•--••....••..................................................=......
0 Description of Soil........................................................................................................................................................................
V .................................. ........-------------------•--.._..-------------•--------------------------------------•----•-----------------------•--•...........................................
0 Nature of Repairs or Alterations—Answer _1__
when applicable_..5 _ _l'---��._.
Agreement: .
The undersigned agrees to install.the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until al ertificate of Compliance has been issued by the board of-health. _
M
._ �.4� ....
Application Approved By ___ �
Da[e
Application Disapproved for the following reasons: -- ---------------------------------------- . ......................................................................
----------------------------------------- ------------------------ ..........-----------------------------------------------------------.............. ------_--------.-....................... ..............--......................
.:.
Permit No. ------------ Issued ..-- .fir' rr�' r- .....
.... ........._...........---..-...--------'----- Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-' TOWN OF BARNSTABLE
Tertif ratr of Tontylinure
THIS IS TO CERTIFY, That the Individual Sewage Disposal.System constructed ( ) or Repaired ( `�
by........................... q-. r 4 .�c .. Q 1 -�-
..�'- ----------------- ---------------------------
Installer_ _
at ....; ----
`�--`-�------------------�-f-�---�---�----------s --....---------------��...s.. .. ��y .�e----...----------........--------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .. ��- ..��....?,�.-- dated -----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT 6E CONSTRUED AS A GUARANTEE THAT THE--
SYSTEM WILL FUNCTION SATISFACTORY.
DATE -- ----- - -------- -----...I I..... � (.....'. .------ -- --. Inspector ....... 'd................................. �-
.........-----..................................
r
THE1COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No..y... '`. ► 4� FEE. 7 . .
�iu�uuttl Turku �unu�riun rruti�
Permission is hereby granted.--------- 0-- ----L=tp--�---
to Construct ( ) or Repair ( L)-an-lndividual Sewage Disposal Sys em
at No..--•-- ... ..............�� ` h '"v ...-....... .
Street - -+"' ,
as shown on the application for Disposal Works Construction Permit NA.. 5___9Q4Dated______________`___....._.....
�- 7.7
Board of Health
DATE ..... ....................................
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS �,,,
PROVIDE PRECAST CONCRETE FINISH GRADE OVER D-BOX= 30.0'+ FINISH GRADE OVER CHAMBERS= 30.0' - 29,7' PROPOSED.VENT WITH CHARCOAL
TOP OF FOUNDATION EXTENSION RISER WITH CONCRETE FILTER TO ABOVE GRA['E
ELEV= 33.0�± COVER TO WITHIN 6"OF FINISH GRADE PLACE CAST IRON FRAME&COVER 3/4"TO 1-1/2"DOUBLE WASHED •-
OVER INLET AND OUTLET COVERS. OVER H-20 CONCRETE RISER 4"SCHEDULE 40 PVC MIN SLOPE 1% 4"PERFORATED PVC PIPE WITH SCREW PLACE CAST IRON FRAME& STONE TO CROWN OF PIPE` GENERAL NOTES
FINISH GRADE
@ FND. EL.= VARIES FINISHED GRADE OVER TANK EL. = 30•0'± 5"DIA. OUTLET(S) TYPE CAP TO WITHIN 3"OF F.G. COVER OVER ALL CHAMBERS 2"OF 1/8"TO 1/2"
SLOPE @ 2%MIN. OVER SYSTEM (SEE NOTE#21) DOUBLE WASHED STONEi 1. UNLESS OTHERWISE NOTED,ALL SYSTEM COMPONENTS AND CONSTRUCTION
20"MIN.ACCESS COVER ADJusTTo REQUIRED METHODS SHALL BE IN ACCORDANCE WITH TITLE 5 OF THE STATE
SLAB (TYPICAL FOR 3) TOP OF SAS= 27.00� GRADE W/MIN.2 OR MAX_4
PROPOSED 4" " " BRICK COURSES OR ENVIRONMENTAL CODE AND ANY APPLICABLE LOCAL RULES.
EXISTING 4" 36 MAX. 9 MIN. EQUIVALENT DIMENSION
PVC SEWER PIPE PROVIDE H-20 9"MIN. 26.00� 36"MAX. - 2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD
SEWER PIPE CONCRETE RISER BREAKOUT EL = 26.50 WITH REINFORCED
CONCRETE COLLARS. OF HEALTH AND THE DESIGN ENGINEER.
-�� �- _ �-------------� 6" 3-- 3"DROP MAX " 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL
___ 2"DROP MIN 3 9 0
1/"MIN SLOPE o o p o BE USED IN DISPOSAL SYSTEM UNLESS OTHERWISE NOTED.
PROVIDE WATERTIGHT
10" " JOINTS(TYP.) 4. TO PREVENT BREAKOUT,THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN
• '` 14" \_*26.61± {AF'PI��JXIMATEC3) 4 PVC IN FROM " � O O O � � , � � � 0 coo � 0 � � 0 O ELEVATION =26.50'FORA DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS
k
- d f SEPTIC TANK 4 PVC OUT TO op 9b
0 0
{SEE NOTE BELOW) LEACHING FACILITY ppp0 o o O A 40 MIL GEOMEMBRANE LINER IS PLACED AT LEAST FIVE FEET FROM S.A.S.AND THE TOP
OUT ELEVATION.
CONTRACTOR ' ' CONTRACTOR SHALL � •_ o o OF THE LINER IS NOT LESS THAN THE BREAK
_ 12" 2 0� 1 10 0 0 0 � � � 0 0 � � 0 O�
' SHALL VERIFY SIZE 48" VERIFY CONDITION OF OUTLET TEE � . o 0 0 ' _",5. 'SLOPE ALCSOLID PIPE AT 1:0%:MINIMUM.
26.34 MIN. 26:17� o 0 0 0 6. THIS SYSTEM 1S NOT IIESIGNED FOR A GARBAGE DISPOS
AL.
AND CONDITION OF EXISTING TEES 22"ZABEL FILTER
EXISTING SEPTIC AND REPLACE AS MODEL#A1801-4x22 6"CRUSHED STONE op 0 0 0 _ 0 0 0 0 po 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO
TANK NECESSARY OVER MECHANICALLY 4.0' 4 0' BACK FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR
COMPACTED BASE - 8.5' (TYP. FOR 1) 3.55' 3.55' INSPECTION. SYSTEM IS NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING
5 4•9' - APPROVAL FROM BOARD OF HEALTH AND DESIGN ENGINEER.
OUTLET DISTRIBUTION BOX 25.0' 12.0' 8. ELEVATIONS BASED ON APPROXIMATE M.S.L DATUM OF 30.00'
TO BE INSTALLED FEET
A LEVEL STABLE GROUND WATER ELEV.= � 18.83� 12.0' ESTABLISHED ON A NAIL SET IN A TREE AS SHOWN ON PLAN.
EXISTING 1000 GALLON CONCRETE SEPTIC TANK BASE.-FIRST Two FEET OF OUTLET 24.00
PIPES TO BE LAID LEVEL. 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION
2 - 500 GAL. H-20 CHAMBERS 5'MIN THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE
*CONTRACTOR TO VERIFY EXISTING CROSS SECTION VIEW •VIEW AT 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY
SEPTIC TANK PROFILE ELEVATION PIORToaNYwoRK& H-20 DISTRIBUTION BOX DETAIL
TYPICAL PROFILE CHAMBER-END
H 2O CHAMBER DETAILS DISCREPANCIES TO THE DESIGN ENGINEER.
NOT TO SCALE NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONCRETE
r STRUCTURES SHALL BE MADE WATERTIGHT.
NOTE: F '� u. TEST PIT DATA 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR
1. MAGNETIC MARKING TAPE SHALL BE ��;. ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH
� MAP 165 � � „� `� �� x � :: PERC. No.: �18so MAP 165 PLACED ALONG THE TOP EDGE OF EACH _ DETERMINATION FROM APPROPRIATE AUTHORITY.
PARCEL 1 r, 4a • ,, INSPECTOR: Donna Miorandi
[" MAP 165 SEPTIC SYSTEM COMPONENT. I1k� ty_ 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS
PARCEL 86 SOIL EVALUATOR: Michael Pimentel, E.I.T.
LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE
PARCEL 85 _ 01% �► �
August 27,2007 THEY SHALL WITHSTAND H-20 LOADING.
DATE
= TEST PIT#: 1 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND
ELEV TOP= 30.00' FINES.
E
A.
- 14. REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM,SUBSOIL AND
A. , WHERE,.. � ELEV WATER= < 18.83 UNSUITABLE MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF
i b
ap tt _ • - LEACHING FACILITY. REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN
► , f PERC RATE_ <2 MIN/IN COARSE SAND FREE FROM CLAY, FINES OR OTHER UNSUITABLE MATERIAL IN
ACCORDANCE WITH 310 CMR 15.255(3).
,,. � �'�,w DEPTH OF PERC= 40"-58"
- 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN
� ,� �A,• �� •��� ��
TEXTURAL CLASS: 1 SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK.
f " 0" 30 QO' 16. PROPOSED PROJECT IS LOCATED WITHIN:
' ;~ ASSESSORS MAP 164 PARCEL 02
Fill OWNER OF RECORD: MARY E. LINEHAN
oD
20" Loa IN STREET
28.33 ADDRESS: 424 MA
m Sand OSTERVILLE, MA 02632
,. y
x ► ► k + ,/ A 10Yr 3/2 ,
.. -.... ^� * " 28.17
:.: , • �� � ���� ...�. 22 FEMA FLOOD ZONE C
LoamySand
B AS SHOWN ON COMMUNITY PANEL# 250001 0016 D
1 OYr 5/6
17. PLAN REFERENCE:
� � �, r 40 26.67' 1. PLAN BOOK 65 PAGE 19(F2)
b f f� t ,r Fine Sand
5 Perc
2.5Y 6/4 DEED REFERENCE
25 17 1 BOOK178 AGE 329 `
25 83 . .
.,. 58
ryy
u 4,
75 P
- ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION.
9+
Medium Sand 20. PROPERTY LINE INFORMATION IS APPROXIMATE, ONLY. THIS PLAN IS TO BE USED ONLY
C-2 2.5Y 6/6
* ��b FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSUME ANY LIABILITY
MAP 165 ._ (Loose) FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE.
PARCEL 120 21. A 4"PERFORATED SCH.40, PVC PIPE SHALL BE PLACED IN A VERTICAL POSITION,TO A
MAP 164 LOCUS PLAN 134." 18.83' DEPTH OF THE BOTTOM OF THE SAS AND EXTEND TO WITHIN 3"OF FINISH GRADE. A
REMOVABLE THREADED CAP SHALL BE PLACED ON THE TOP TO ALLOW FOR INSPECTIONS.
PARCEL 7 `
' SCALE: 1"= 1000' No Standing,Weeping,or
Mottling Observed
TEST FIT DATA
w w°
PERC. NO.: 11880
d' INSPECTOR: Donna Miorandi LEGEND
DESIGN DATA
�z SOIL EVALUATOR:'Michael Pimentel, E.I.T.
w' DATE: August 27,2007
w
--100 - - - - EXISTING CONTOURS
Nail in Benchmark
Tree �'�26 mow= TEST PIT#. 2
NUMBER OF BEDROOMS 3 102 PROPOSED CONTOURS
Elev. =30.00' - -- DESIGN FLOW 110 GAUDAY/BEDROOM ELEV TOP= 30.50'
Approx. M.S.L. ,"� � �
MAP 164 - - - �'� TOTAL DESIGN FLOW 330 GAUDAY ELEV WATER= < 19.33' 102 PROPOSED SPOT GRADE
/ , X-X-X-X/ DESIGN FLOW X 200 % = 660 GAUDAY PERC RATE_ X-X-X-X-X-' FISTING FENCE LINE
PARCEL 8 / � � � ;--X''X�X-'��- �-.�-3�
TP 1 USE EXISTING 1000-GALLON SEPTIC TANK DEPTH OF PERC=
O 30.00' TP 2 ❑/H/W EXISTING OVER-HEAD UTILITIES
30.50' TEXTURAL CLASS: 1 W W EXISTING WATER LINE
/��/ /�`� (2 - v INSTALL 2 - 500 GALLON H-20 CHAMBERS o" 30.50' TEST PIT LOCATION
'o (4) - �`1�i SIDEWALL CAPACITY Fill Q Q EXISTING 1000 GALLON SEPTIC TANK
PROPOSED PVC VENT(EXACT.LOCATION PER OWNER) _ _3 (1) HC-2 20" 28.83' PROPOSED 4"SOLID SCHEDULE 40 PVC PIPE
<' (LENGTH +WIDTH)(2)(2'HIGH) (0.74 GPD/S.F.) = GAUDAY A Loamy Sand
1 OYr 3/2
APPROXIMATE LOCATION OF EXISTING INFILTRATORS PER"` j� �� (25.0'+12.0') (2)(2') (0.74 GPD/S.F.)= 109.5< GAUDAY 22" 28.67' Q PROPOSED H-20 DISTRIBUTION BOX
SEPTIC AS-BUILT CARD (TO t REMOVED, IF NECESSARY) #424 �`� � \ B Loamy Sand 0 PROPOSED 500 GALLON H-20 LEACHING CHAMBER
HCA EXISTING `` (I MAP 165 BOTTOM CAPACITY 1 OYr 5/6
EXISTING DISTRIBUTION BOX 3-BEDROOM 1 40" 27.17'
- DWELLING 1 PARCEL 87 Fine Sand
j
TOF=33,0't (LENGTH x WIDTH ) (.74 GPD/S.F.) = GAUDAY C-1 50" 2.5Y 6/4 26.33'
EXISTING 1000 GALLON SEPTIC TANK (OUTLET TO / / C w (25.0'x 12.0') (.74 GPD/S.F.) = 222.0 GAUDAY REV. DATE BY APP'D. DESCRIPTION
EXISTING DISTRIBUTION BOX TO BE PLUGGED) -�" _34 ;' � �� PROPOSED SEPTIC SYSTEM UPGRADE
/ Medium Sand PREPARED FOR:
SWING TIES v PROPOSED H-20 DISTRIBUTION BOX R• �� TOTALS:
- 2,5Y 6/6
• CAPEWIDE ENTERPRISES
(Loose) ,
DESCRIPTION HCA HC-2 PROPOSED 2-500 GALLON H-20 LEACHING CHAMBERS MAP 164 \ �`� / TOTAL NUMBER OF CHAMBERS: 2 LOCATED AT
3 TOTAL.LEACHING AREA: 448.0 S FT.
LEACHING CORNER(1) 18.4' 40.1' 3 134" 19.33
PROPOSED INSPECTION PORT(SEE PROFILE) PARCEL 2 ` r ,- �38 TOTAL LEACHING CAPACITY: 331.5 QAL./DAY 424 MAIN STREET
LEACHING CORNER(2) 29.4 44.6 43,560t S.F. OSTERVILLE, MA 02632
1 q0 No Standing,Weeping, or
LEACHING CORNER(3) 44.1' 26.0' MAP 164 v \ "''- /' Mottling Observed
LEACHING CORNER(4) 37.7' 17.1' PARCEL 1
p0' \ RESERVED FOR BOARD OF HEALTH USE SCALE: 1 INCH = 20 FT. DATE: SEPTEMBER 5, 2007
125' 0 10 20 40 80 FEET
JOHN L. u
CHURCHILL PREPARED BY:
CRL JC ENGINEERING, INC.
ti No. 1807
2854 CRANBERRY HIGHWAY
EAST WAREHAM, MA 02538
SITE PLAN 508.273.0377
SCALE: 1"=20' Drawn By: MCP Designed By:MCP Checked By:JLC JOB No.1275
i
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