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Commonwealth of Massachusetts 001
ro Title 5 Official Inspection Form
E Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f,
438 Main Street '
Property Address
Sharon Taylor r )
Owner Owner's Name
information is required for every OSterville V Ma 02655 7/29/2020
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please.see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information S A/003
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
r Company Address
Centerville Ma 02632
Y"K City/Town State Zip Code
re 774-248-4850 smjonestitle5@gmail.com, S14522
sean@srr-,jonestitle5.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 16.000); 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 maintenanice 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 F
7/29/2020 .
Inspector's Sicnature Date
The system Jnspector 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 offi:e 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
J
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
J Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t ��
438 Main S:rezt
Property Address
Sharon Tay or
Owner Owner's Name
information is required for every Osterville Ma '02655 7/29/2020
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:
® 1 have not found any information which indicates that any of the failure criteria described
in 31�0 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The property located at is served by a Title V septic system consisting of a 1000 gallon septic tank,
distribution 'box and 2 500 gallon precast leach chambers. Although the system was found to be in
proper working condition at the time of inspection this report does not guarantee future performance
under similar or increased usage.
2) System Conditionally Passes:
❑ One cr 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
1. Title 5 Official Inspection Form
w Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
438 Main Street
Property Address
Sharon Tayeor
Owner Owner's Name
information is Osterville Ma 02655_ 7/29/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pum,p Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumas/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
systen 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 sysem is failing to protect public health, safety or the environment.
a. Sys-,em will pass unless Board of Health determines in accordance with 310 CMR
15.30311)(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
1. Title 5 Official Inspection Form
l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
438 Main Street
Property AddresE
Sharon Taylor
Owner Owner's Name
information is required for every Osterville Ma 02655 7/29/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety, and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply..
❑ The system has a septic tank and SAS and the'SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more f-om 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
❑ 1® 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
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
438 Main Street
-u�
Property Address
Sharon Taylor
Owner Owner's Name
information is required for every Osterville Ma 02655 7/29/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ Z 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.
❑ E Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the.failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the
questions in Section CA.
Yes No -
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area-IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Iy Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
;• 438 Main Street
Property Address
Sharon Taylcr
Owner Owner's Name
information is required for every Osterville Ma 02655 7/29/2020
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you ha4e 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?
® ❑i 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
438 Main Street
Property Address
Sharon Taylo
Owner Owner's Name
information is required for every Osterville Ma 02655 7/29/2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN f ow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
Descriptio-i:
Number of current residents: 5
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: current
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
l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
438 Main Street
Property Address
Sharon Taylor
Owner Owner's Name
information is required for every Osterville Ma 02655 7/29/2020
page. Cityrrown 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 pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i� 438 Main Street
Property Address
Sharon Taylor
Owner Owner's Name•
information is required for every Osterville Ma 02655 7/29/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ . Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
system repaired 2003 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
438 Main Street
Property Address
Sharon Taylor
Owner Owner's Name
information is Osterville Ma 02655 7/29/2020
required for every
page. Cityrrown 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 0 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:
1000 gallons
5„
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 3
Scum thickness 211
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.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1=1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
y •,��%% 438 Main Street
Property Address
Sharon Taylor
Owner Owner's Name
information is required for every Osterville Ma 02655 7/29/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth be'tow 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 IeveV's 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 El 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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
; - 438 Main Street
^1'
Property Address
Sharon Taylor
Owner Owner's Name
information is required for every osterville Ma 02655 7/29/2020
page. City/Town State Zip Code Date of Inspection
D. System, Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm leve: Alarm in working order: ❑ Yes ❑ No
Date of las 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 Olt
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 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
438 Main Street
Property Address
Sharon Taylor
Owner Owner's Name
information is Osterville Ma 02655 7/29/2020
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
�m Title 5, Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
438 Main Street
Property Address:
Sharon Taylor
Owner Owners Name
information is required for every Osterville Ma 02655 7/29/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation etc.):
Leaching facHity was video inspected and found with 6" standing water and no signs of past hydraulic
overloading.
s
3
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 o'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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�-j 438 Main Street
Property Address
Sharon Taylor
Owner Owner's Name
information is required for every Osterville Ma 02655 7/29/2020
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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
s
Commonwealth of Massachusetts
t
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i .
i
438 Main Street
Property Address
Sharon Tarylor
Owner Owner's Name
information is required for every Osterville Ma 02655 7/29/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provida 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 bullding. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
ly(�
r
0
LT
AZ
�3 25-
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
�ro Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t m
i 438 Main Stree'
Property Address
Sharon Taylor
Owner Owner's Name
information is required for every Osterville Ma 02655 7/29/2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check.cellar
❑ Shallcw 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:
Groun6tater 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
�u Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
t_
438 Main Stree-
Property Address
Sharon Taylor
Owner Owner's Name
information is required for every Osterville Ma 02655 7/29/2020
page. Citylrown State Zip Code Date of Inspection
E. Report C.0ompleteness 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. Sy=tem 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
i
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Bk 249,82 P:941 5 r 756
DEED RESTRICTION
WHEREAS, JOHN T. GANEY and ELIZABETH M. GANEY are the owners of the
land and building at 438 Main Street, Barnstable (Osterville), MA and being shown as
LOT 21 on a plan entitled 'Revision of Lot #18 as shown on Subdivision Plan of Land in
Osterville, MA, Property of Thomas J. Powers and John J. Doherty' which said plan is
recorded in the Barnstable County Registry of Deeds in Plan Book 140, Page 73;
WHEREAS, the said owners of the Property has agreed with the Town of
Barnstable Board of Health to a restriction as to the number of bedrooms which can be
included in any home located on said lot as a pre-condition to obtaining a building permit
for a Game Room to be included on the third*floor of a detached garage to be constructed
on said lot;
WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to the
issuance of said permit by the Building Commissioner, is requiring that the agreement for
the 'restriction on the number of bedrooms in any house now existing or hereafter'
constructed on the lot be put on record with the Barnstable County Registry of Deeds by
recording this document,
NOW, THEREFORE, the said owners do hereby place the following restriction on
their above-referenced land in accordance with their agreement with the Town of
Barnstable Board of Health,.which restriction shall run with the-land and be binding upon
all successors in title:
1. The dwelling located or to be located on the Property may have no more than
three (3) bedrooms and the said Game Room may not be used as a bedroom.
f a
2. It is agreed that this shall be a permanent deed restriction affecting-the Property.
3. It is further agreed that this restriction will terminate upon the connection of the
Property to municipal- -sewer or municipal water thereby allowing additional
bedrooms under the then applicable provisions of the said State Environmental
Code: ;
For title see deed from to the'said owners dated November 28, 2005 and recorded
with said Deeds in Book 20533, Page 155.
i
4
Executed as a sealed instrument this—Ur day of November, 2010.
JOHW . GANEY
ELIZABETH M. GAN
STATE OF CALIFORN[A
County of
On this ; , day of November, 2010, before me, the undersigned notary public,
g rY p ,
personally appeared JOHN T., GANEY and ELIZABETH M. GANEY and proved to me
through satisfactory evidence of identification, -which was a ] [ )
passport, or [ ] personally known to me, to be the person whose name is signed on the
preceding or attached document, and acknowledged to me that they signed it voluntarily
for its stated purpose.
Notary Public
My commission expires:
. 2
STATE OF CALIFORNIA
COUNTY OF CONTRA COSTA
On November 5, 2010, before me, S.'Weed,Notary Public in and for said state, personally
appeared
JOHN T. GANEY AND ELIZABETH M. GANEY
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same_
in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument
the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws`of the State of California that the
foregoing paragraph is true and correct.
WITNESS my hand and official seal.
.�.:.. S. WEED
COMM.#1907327
NOTARY PUBLIC�CALJWRNU►
CONTRA COSTA COUNTY -�
Comm.Exp.OCT.9,2014
eed.
o
BARNSTABLE REGISTRY OF DEEDS
TOWN OF BA�NSTABLE POO
LOCATION �� � l SEWAGE#
VILLAGE S ✓'_t_i � ASSESSOR'S MAP & LOT !
INSTALLER'S NAME&PHONE NO. Re 6/ A,,S d ),,? �—
SEPTIC TANK CAPACITY Ica Q-4-) ;_►_�
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER KAC. A i A
PERMITDATE: �'Z'"d-�-- 3 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Le ching Facility Feet
Private Water Supply Well and Leaching Facility (If wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetl ds exist
within 300 feet of leaching facility) Feet
Furnished by
nvi
17 v
q.
No. -�! Fee.,.Q'00- 3 r 0
'
z THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i/
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2ppfication for Migaar *pgtem. Construction Permit
Application for a Permit to Construct( . )Repair( Upgrade( )Abandon( ) El Complete System O Individual Components
Location Address or Lot No. Owner's Name Address and Tel.No. —
438 Main Street Jennifer Kachajian
Assessor•sMap/Parcel Ostervllle., MA 438 Main St. , Osterville, MA
164-001
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. 9 4 6—8 8 8 6
Wm. , E. Robinson Septic Cannon Engineering
PO Box 1089, Centerville, MA 11 Brenrae Dr. , Middleboro,MA.
Type of Building:
Dwelling No.of'Bedrooms 3 Lot Size sq.ft. Garbage Grinder(lo)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Install new Title 5 leach
system to Flans of Cannon Engineering #164-001
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 9f Title 5 oft vironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu s oard of Health.
Signet Date ]Z 22_2�
Application Approved by Date D_d2-0)
Application Disapproved for the Yollowi4 reasons
Permit No. 2 hd —6:i E O Date Issued
No. Duo U - 1? Fee$50.00
THE COMMONWEAGC'rH OF MASSACHUSETTS, , i Entered in computer:
f � PUBLIC. HEALTH DIVISION -TOWN OF.BARNSTABLE., MASSACHUSETTS Yes
vr-
appYication for Miopoal bpgtem Cow6truction permit
Application for a Permit to Construct( )Repair( �Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. Own is Name, ddress and Tel.Nq. , }
438 Main Street ow Kacha] ian
AssessorsMap/Pazcel Ostervill MA 438 Main St. , Osterville, MA
164-001
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. — o
Wm. , E. Robinson Septic Cannon Engineering
PO Box 1'089,' Centerville, MA 11 Brenrae Dr. , Middleboro,MA.
1�pe of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons. f
Plan Date Number of sheets Revision Date
Title 1
Size of Septic Tank Type of S.A.S.
Description of Soil
i
P
Nature of Repairs or Alterations(Answer when applicable) Install new Title 5.- leach
system to plans of Cannon Engineering #164-001
_j Date last inspected: A,
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system `
1n accordance with the provisions of Title 5 of e-Environmental Code and not to place the system in operation until a Ciertifi-
Cate of Compliance has been issued fi QBoard of Health.
_ Signed Z 2Z.o,�
Application Approved by ) v _ - Date
Application Disapproved for the,following reasons -"
3-3 r
w
Permit No. 2 Du S o Date Issued f J `
THE COMMONWEALTH OF MASSACHUSETTS
Kachaj ian
BARNSTABLE, MASSACHUSETTS
A,
I-, Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( )
Abandoned(( )by Wm. E. Robinson Septic Service
at 43f3 Main St. , Osterville, MA has been constructed in accordance
with the provisions of Title 5 and the for.Disposal System Construction Ferinit No. 2003,00 dated
Installer Designer
The issuance of thi's permit shall not be construed as a guarantee that the sRFrn will Mriction as desl ned.._
Date >I Inspector w.�� �'t J ��c9
---------------------------------
No. 2003 - Fee;$50.00
Kachaj ian THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Miopogal *p.5tem Cow5truction Permit
Permission is hereby granted to Construct( )Repair(X)Upgrade( )Abandon( )
System located at 438 Main St. , Osterville, MA
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of thgs pie. A (�
Date: 1 a I �l 3 Approved by
TOWN OF BAgNSTABLE
.2
LOCATION �� ��> L, 1� L SEWAGE# �G
�j ASSESSOR'S MAP & LOT 6 'UO f
VILLAGE /
INSTALLER'S NAME&PHONE NO. '0�/ �.� d ` �. 517--7
SEPTIC TANK CAPACITY
at. �, L—
LEACHING FACILITY: (type)Jz "L (size)
NO*OF BEDROOMS
BUILDER OR OWNER 1)
PERMIT DATE: _COMPLIANCE DATE:
Separation Distance Between the: ,
Maximum Adjusted Groundwater Table to the Bottom of Le ching Facility Feet
Private Water Supply Well and Leaching Facility (If wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetl ds exist Feet
of facility)
facili
within 300 feet o
Furnished by
!I
Iy
� 1/1A
Ci
ti
NORM SOIL EVALUATOR FORM
Page 1 of 3
No.
Date: 2/18____ /_ 2-03
Commonwealth of Massachusetts
Osterville, Massachusetts
Soil Suitabilit AsseSSment foj On-site Serva a Dis osal
Performed BY: ,forge De Sousa
Witnessed: Sam White, Barnstable B.O.H.
LocationAddress or Date: 9/18/2003
Lot# owner's Name, Address,
�j and Telephone#
438 Main St. ��
Cannon Engineering
New construction [ ] Repair [X]
Office Review
Published Soil Survey Available: No [X] Yes [ )
Year Published: Publication Scale:
Drainage Class: Soil Map Unit:
Surficia) Geological report Available: No [X] Yes Soil Limitations:
Year Published [ ]
Publication Scale
Geologic Material (Map Unit)
Landform:
Flood Insurance Rate Map: 250001 0016 D July 2, 1992
Above 500 year flood boundary No
[ ) Yes [X]
Within 500 year flood boundary No [X] Yes [ j
Within 100 year flood boundary No1X' 1 Yes [ ]
Wetland Area:
National Wetland Inventory Map(map unit):
Wetlands Conservancy Program Map(map unit):
Current Water Resource Conditions(USGS) Month: August 2003
Range: Above Normal [XI Normal [ ) Below Normal [
Other Rcferences Reviewed:
t UT A1111Rovt;1)FORM
12/07/JS ..
r-vrcm sOIL EVALUATOR FORM
Location Address or Lot No. 438 Main St t
On-Site Review
Deep Hole Number: 1 Date: 9/18/2003
Location(identify oti site plan)see attached sketch Time: 10:00 Weather: Sur
Land Use: Residential
Vegetati8n: Slope(%): 5-10% Surface Stones:
Landform:
Position on landscape(sketch on the back)
Distances from:
Open Water Body>106 feet Drainage way . feet
Possible Wet Area>100 . feet Property Line>10 feet
Drinking
Water Well.>1 UO feet Other
DEEP OBSERVATION HOLE LOG'
Depth from Soil Horizon Soil Texture
Surface(inches) Soil Color Soil Other
(USDA) (Muncell) Mottling Structure,Stones, Boulders,Consistei
0-5 p Gravel) '
P .
.5-14 Fill
14-16 Al Sandy Loam 10YR2/2 friable, massive throw g.hout
16-21 A2 Sandy Loam 10YR3/6
21-36
B Medium .
Sand 10YR4/6
36-120 C 2.5Y5/4
Medium
Sand
•MINIMl1M C)F 2 lIROL.1.S RIi(jlllRfh AT GV..RY.l'R0 0SFI)DISI'o%Al,AREA
Parent Material(geologic): Pro glacial Outwash
D e
-� Depth to Bedrock. > 120
__pth to Groundwater. Standing Water in the Hole: r
Weeping from Pit face:
Estimated Seasonal]-ligh Ground Water: 120" bottom of test it
DEP APPPROVED FORM-12/070.5
r
FORM.12—PERCOLATION TEST
Location Address of Lot No. 438 Main St.
COMMONWEALTH OF MASSACHUSETTS
Ostterville, Massachusetts
Percolation Test*
•• Date: 9/18/2003 Time: 9:56
Observation Hole#
1 -
Depth of Perc
40
Start Pre-soak
9:5G
End Pre-soak
9:59
Time at 12"
Time at 9"
Time at G°
Time(9„-G„�
24 81/15 min.
Rate Min./Inch
<2 min./in.
• Minimum of I percolation test must be performed in both the primary area and reserve area.
Site Passed [XI Site Failed [
Performed By: Jorge - De Sousa
Witnessed By: Sam White..Barnstable B.0.111.
Comments:
DET APPROVED FORM-1I2/o7/95
9
FORM I I — SOIL EVALUATOR FORK
Page 3 of 3
Location Address or Lot No. 438 IV�St,
Determination or Seasonal Hi h Water Table
Method Used:
[ ),, Depth observed standing in observation hole inches
[ ) Depth weeping from side of observation hole
[ ) Depth to soil mottles inches inches
[ ) Ground water adjustment feet
Index Well Number Reading Date Index well level
Adjustment factor Adjusted ground water level: 120" (bottom'of test pit)
)
Depthof Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas
observed throughout the area proposed for the soil absorption system? Yes
If not, what is the depth of naturally occurring pervious material
Certificationcertify that on 4/16/2002 (date) 1 have passed the soil evaluator examination approved b the De
partment or En
Protection and that the above analysis was performed by me consistent with the required training,expertise and ex
in 310 CMR 15.017.
Signature �7-
-- Date
T—
DEP APPROVED FORM•12/07/95
t+, _ r�i
Wm. E. Robinson, Jr.
Septic Inspections
43 Tomahawk Drive
Centerville, MA 02632 .
(508) 775-7986
Pager 978-622-8700
8<9
o
0
Location
438 Main St.
Osterville, Ma 02665
McRay
System is Title-5 and in good working condition. .
s
t
f ,
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIROMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECION (�
ONE WINTER STREET, BOSTON MA 02108(617)292-5500 16
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
PROPERTY ADDRESS: 438 Main St.Osterville M_ a 02565 ADDRESS OF OWNER:
DATE OF INSPECTION: 9-8-99
NAME OF INSPECTOR: Wm. E. Robinson
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000)
COMPANY NAME: Wm.E.Robinson Septic Inspections
MAILING ADDRESS: 43 Tomahawk Dr.Centerville Ma 02632
TELEPHONE NUMBER: 508-T75.7986
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:
X PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS
t
INSPECTORS SIGNATURE: DATE: 9$-99
The system Inspector shall submit a copy of this inspection repot to the Approving uttwrity(Board of Health or DEP) 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 appropriate regional office of the Department of Environmental Protection. The original
should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
NOTES AND COMMENTS:System is title-5 and in good working condition at time of inspection.Septic tank
was cleaned after inspection.Tank should be cleaned every two years.
revised 9/2/98 _ 1
. 6
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIVICATION(continued)
Property Address: 438 Main St.Osterville Ma 02665
Owner: Susan McRay
Date of Inspection: 9-8-99
INSPECTION SUMMARY: Check Al B,C,orD:
Aj SYSTEM PASSES:
X I 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.
COMMENTS: SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME
OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM.
B SYSTEM CONDITIONALLY PASSES: NIA
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.
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 flank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate
of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the
inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,stows substantial infiltration or
exfiiltration,or tank is 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.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s)or dire to a broken,settled or uneven distribution box. The system will pa
pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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
revised 9/2/98 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 438 Main St.Ostervilie Ma 02665
Owner: Susan McRay
Date of Inspection: 9-8-99
C]FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: NIA
Conditions exist which require furttmr 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 IN ACCORDANCE WITH 310 CMR 15.303 .
(1)(b)THT 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 ANY)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND
SAFETY AND THE 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 soil absorption system and the SAS is within a Zone
1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet
of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100
feet but 50 feet or more from a private water supply well,unless a well water analysis for coGform
bacteria and volatile organic compounds indicates that the well is free from pollution from that faciiliity
and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than 5 ppm. Method
used to determine distance (approximation not valid).
3) OTHER
t
revised 9/2/98 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 438 Main St Osterville Ma 02665
Owner: Susan McRay _.
Date of Inspection: 9-8-99
D]SYSTEM FAILS: WA
You must indicate either'Yes'or'No' to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR
16.303. The basis for this damnation is identified below. The board of Health should be contacted to
Determine what will be necessary to correct the failure.
Yes No
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 wags due to an over-
Loaded or ckKjged SAS or cesspool.
Static liquid level in the distribution boot above outlet invert due to an overloaded or clogged
SAS or cesspool.
Liquid depth in cesspool is less than ti below invert or available volume is less than%day flow
Required pumping more than 4 times in the last year NOT due to dogged 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 surface water supply or tributary to a
Surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or pmry 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 prorate
Water supply well with no acceptable water quality analysis. If the well has been analyzed to be able,
attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate
E) LARGE SYSTEM FAILS: WA
You must Indicate either*Yes"or'No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 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 foWwing conditions exist:
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
Mapped Zone 11 of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local
regional office of the Department for further information.
revised 9/2/98 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 438 Main St.Osterville Ma 02665
Owner: Susan McRay
Date of Inspection: 94-N
Check if the following have been done:You must indicate either"Yes'or'No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and the system
X has not 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.
X As built plans have been obtained and examined. Note if they are not available with NIA.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,including the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interims of the septic tank was
X Inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid
X Depth of sludge,depth of scum. The size and location of the Sal Absorption System on the site
X Has been determined based on:
X Existing information.Ex.Plan at B.O.H.
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation
X of distance is unacceptable)[I5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on
X the proper maintenance of Sub-Surface Disposal System.
Y
revised 9/2/98 5
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
• PART C
SYSTEM INFORMATION
Property Address: 438 Main St.Osterville Ma 02665
Owner: Susan McRay
Date of Inspection: 9.8-99
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom for SA.S.
Number of bedrooms(design) 3 Number of bedrooms(actual): 3
Total DESIGN flow 330
Number of current residents: 4
Garbage grinder(yes or no): No
Laundry(separate system) (yes or no): No If yes,separate inspection required
Laundry system inspected(yes or no): NIA
Seasonal use(yes or no) No
Water meter readings,if available(last two(2)year usage(gpd): 98-58 k 97-90 k
Sump Pump(yes or no): No
Last date of occupancy: 9-99
COMMERCIAL/INDUSTRIAL: NIA
Type of establishment:
Design flow. Gpd(Based on 15.203) -
Basis of design flow
Grease trap present:(yes or no):
Industrial Waste Holding Tank present:(yes or no)
Non-sanitary waste discharged to the Title 5 system:(yes or no)
Water meter readings,if available:
Last date of occupancy.
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
WA Town of Barnstable DPW
System pumped as part of inspectiOn:(yes or no) No
If yes,volume pumped: Gallons
Reason for pumping .
TYPE OF SYSTEM
x Septic tanktdistribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract.
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known)and source of information:
N/A yrs.As-built card.,
Sewage odors detected when arriving at the site:(yes or no) No
revised.9/2/98 6
L
St;BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 438 Main St Osterville Ma 02665
Owner: Susan McRay
Date of Inspection: E-8-"
BUILDING SEWER: NIA
(Locate on site plan)
Depth below grade:
Materiel of construction _ cast iron _ 40 PVC other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints:_venting,evidence of leakage,etc.)
SEPTIC TANK:
(Locate on site plan)
Depth below grade:
Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes1w)
Dimensions: 5'x9'x6' 1000 GST
Sludge depth: 4'
Distance from top of sludge to 5attom of outlet tee or baffle: 27'
Scum thickness: 5°
Distance from top of scum to top of outlet tee or baffle: T
Distance from bottom of scum:o bottom of outlet tee or baffle: 9'
How dimensions were determined Probed
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.)
Tank is in good working condition and was cleaned after inspection.(1000 gals.)
GREASE TRAP: NIA
(locate on site plan)
Depth below grade:
Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene other(e)plain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,;ondition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
revised 9/2/98 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART C
SYSTEM INFORMATION(continued)
Property Address: 438 Main St.Osterville Ma 02665
Owner: Susan McRay
Date of Inspection: 9-8 99
TIGHT OR HOLDING TANK: NIA (Tank must be pumped prior to,or at time,of inspection)
(Locate on site plan)
Depth below grade:
Material of construction _ Concrete _ metal _ Fiberglass _ Polyethylene _ other(e)plain)
Dimensions:
Capacity: Gallons
Design flow: gallonsldey
Alarm present
Alarm level: Alarm in working order Yes; No
Date of previous pumping:
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: =equal
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,)
D-Box is in good working condition(44")
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
k
revised 9/2/98 8
C
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 438 Main St.Osterville Ma 02665
Owner: Susan McRay
Date of Inspection: 6 8-99
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan,if possible excavation not required,but may be approximated by non4ntrusi4e methods)
If not located, explain:
Type:
Leaching pits,number: 1-LP1000
Leaching chambers.number.
Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number,
Alternative system:
Name of 7ethnology:
r
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
1-Lp 1000 less than'/4 full with no stain at time of inspection.
CESSPOOLS: N/A
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids toyer.
Depth of scum layer.
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments::
(note condition of soil,signs of iydraulic failure,,level of ponding,condition of vegetation,etc.)
PRIVY: N/A
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(rote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
revised 9/2/98 . 9
s
V '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART C
SYSTEM INFORMATION(continued)
Property Address: 438 Main St Osterville Ma 02665
Owner: Susan McRay
Date of Inspection: 941-99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchnvift
locate all wells within 1 W(locate where public water supply comes into house)
' lb
S
V
y ,
revised 9/2/98 10
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 438 Main St.Osterville Ma 02665
Owner: Susan McRay
Date of Inspection: 9-8-99
NRCS Report name
Sal Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater 40t Feet
Please indicate all the methods used to determine High Groundwater Elevation:
X Obtained from Design Plans on record
X Observation of Site(Abutting property,observation hole,basement sump etc.)
Determine it from local conditions
X Check with local Board of health '
Check FEMA Maps
Check pumping records
Check local excavators,installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(Must be completed)
House is built on high ground area.
revised 9/2/98 11
y ,
SUBSURFACE BEIIAGE DISPOSAL SYSTEM INSPECTION �'RM
Address of property i �!� � ► S EP
Owner's name r�( � .e Q II �r r� ,v! C�
G 1995
Date of Inspectionu�88yyg���,�,��
PART A
CHECKLIBT Y
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
l� 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
k system recently or as part of this inspection.
v As built plans have been obtained and examined.. Note if they are not
available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
.P
1/ The site was inspected for signs of breakout. 4
•./,/ All system components, excluding the SAS, 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.
P The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
ZThe facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance 'of SSDS.'
,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
.If residential
number of bedrooms
C) number of current residents
N garbage grinder, yes or no,
laundry connected to system, yes or no
1,4 seasonal use, yes or no
If nonresidential, calculated flow:
Water meter readings, if available: r
� . C Last date of occupancy
GENERAL INFORMATION
Pumping records and sou ce of information:
System pumped as part of inspection, yes or no
if yes, volume pumped
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. Source of
information: '1
C S
Sewage odors detected. when arriving at the site, yes or .no
c .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INF RMATION continued
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 and number
leaching chambers and number
leaching galleries and 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, recommendations for maintenance or repairs,etc.-)
CESSPOOLS (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 (cesspool must be pumped' as
part of inspection) '
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc.)
PRIVY:
(locate on site plan)
materials of construction
dimensions
depth of solids
-comments.:
(note condition of soil, signs of •hydraulic failure, level of ponding,
condition of vegetation,- recommendations for maintenance or repairs,etc. ) .
. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
. / SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
t�
depth below grade:_1____
material of construction. VVV concrete metal FRP other(explain)
dimensions:
62 sludge depth
, OY distance from top of sludge to bottom of outlet tee or baffle
_0 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 outiet. invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
tp,r Lv,
DISTRIBUTION BOX: (/
(locate on site plan)
depth of liquid level above outlet invert
Comments:
.(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, 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. -
recommendations for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined", explain why not)
Backup_ of sewage into facility?
I� Discharge or ponding of effluent to the surface. of: the ground or
surface waters?
Static liquid level in the distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 2/2 day
flow?
Required pumping 4 times or more in the last year?
number of times pumped
Septic tank is metal? cracked?structurally unsound? substantial
'infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS,, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone I of a public well?
within 50 feet of a bordering vegetated wetland or salt marsh.-
(cesspools and privies only, not the SAS)?
4
t
,. within 50 feet of a private water supply well?
• less than 100 feet but greater than 50 feet from a " rivate water
.L_. g P
supply well with no acceptable water quality analysis? . If the well
F has been analyzed to be acceptable,, attach copy of well water analy
for coliform bacteria, volatile organic compounds, ammonia nitrogen
.,and nitrate nitrogen.
SUBSURFACE SEWAGE DISPOSAL SYSTEM .INSPECTION .FORK
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE L:SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within loot
e
u
• �•-�- :•� . i
DEPTH TO GROUNDWATER
depth to groundwater
method of determination or approximation:
r
SUBSURFACE SEWAGE DISPOSAL 8YSTEK INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector� ,t� �C�
Company Name
Company Address f ,,�
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Chec one:
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15.303. Any failure criteria not evaluated are As stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303. The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector's Signature
i 1 �
Date 47_ �_ C
Original to system ownert..
Copies to: '= , -
Buyer (if applicable)
Approving authority
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DIMEN51ONAL REQUIREMENTS '
ZONING CLA551fICATION: RG
MINIMUM LOT 51ZE: 43560 5F
MINIMUM FRONTAGE: 20' m ,
MINIMUM FRONT YARD: 20'
MINIMUM 51DE t. REAR YARD: . 10'
BUILDING LOCATION PLAN
FOR
438 MAIN STREET OSTERVILLE, MA
PREPARED FOR
JOHN * ELIZABETH GANEY
O �yG SCALE: DATE: DRAWN BY: ^
Ru A. 1 A`A,
" = 40' 10.-07-2010 T IV'VV
No.35 1 JOB NUMBER: REVISION: 5HEET NUMBER:
08-0 I G CPP-
gtiosuR � WELLER A550CIIATE5
1645 FALMOUTH RD., SUITE 4C -- P.O. BOX 417 CENTERVILLE,_MA 02632
1 u _ 2 WINDY WAY, #232 NANTUCKET, MA 02554
TELEPHONE t FAX: (508) 775-0735
EMAIL: trl5welier@comca5t.net
REGISTERED LAND SURVEYORS ENVIROMENTAL CONSULTANTS
i
1
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TOWN OF BARNSTABLE
�jOCATION
�( A"' �J SEWAGE #
VILLAGE ��STeT06-E- ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
may'SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) -CL4St' a-- (size)�. ,C(Q
NO.OF BEDROOMS
BUILDER.OR OWNER O C� QU—
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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DRAWN BY- KW
DATE: 3/28/12
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----- — --- ___-- DRAWN BY- KW
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DRAWN BY= KW
DATE: :V28A9 .
TA
23 a +
RETAINING WALL -
P.T.2 x 10 LEDGER BOARD LAG BOLTED TO 23-g '
SOLID BLOCKING W!(2)LEOGERLOK BOLTS
16"o.c.W/JOISTS HAIJGERS AT BOTH ENDS -
tt'-1012" -
P.T.6 x 6 POSTS ON 12-OIA A7
CONCRETE SONOTUBES �,
A TO 47 BELOW GRADE USE 9-31/2• A7 SIMPSON ABU 66 POST B 2 7" 9'-3 7Q"ASE E ' t
. SIMPSON AC61LCE4 - ..
POST CAPS
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IS Rp°IL HEIGHTS -
Iq._4• ACCESS
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x 6 FIR BEAM
————————— ---- _
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B..x6-SHELF'
RETAINING WALL e. 'AT L.
a 4'-4" ACCESS _
_ PANEL I MATCH CHECK ACCESS 4_4_
PANEL b .
-
.RAIL HEIGHTS I b -
' a.
AT 4 a V-3 U2'
23.-g"-
LOWER LEVEL PLAN
SECOND FLOOR PLAN
Ir
I
SYSTEM PROFILE
FINISHED GRADE ELEV = 100.0 FINISHED GRADE ELEV = 100.0
- - - - - 12" min. COVER
36" MAX. cover
. - • :.,. slope = .01 slope = .01
3" min. speed level at each distirbution pipe 97.38
6" min. 96.64
F���z 2" min. 3" max. IL slope = .01 1/8" TO 1/2"
/ .i. ; WASHED STONE
flow line oo O o0 3/4" TO 1 1/2"
10" min. 14 96.66 2.0 96.47 oc c =Co WASHED STONE
2" min. 6" min. 96.40
94.40
DISTRIBUTION BOX 7.0' 13.17'
TO BE SET ON 6" OF CRUSHED STONE
S ITE ] -ILANPLACED ON A COMPACTED LEVEL BASE 5' SEPARATION AS REQUIRED BY
OF BY TITLE
IFTEPROV FOR
1 PROVIDED
PERC > 2 MIN./IN.
USE EXISTING 1000 NONE ELEV 75.9
H-10 LOADING REQUIRED
�- GAL. SEPTIC TANK DISTRIBUTION BOX GROUNDWATER ELEVATION
lM.�ods1
OUTLETS
e PLUGGED 4
--�' DISTRIBUTION BOX LEACHING CHAMBERS
LOT 19 NOT TO SCALE NOT TO SCALE
LEGEND
TIP
TEST PIT W - WATER LINE 100.00- EXISTING CONTOUR LINE
EXISTING FENCE 100.00 PROPOSED CONTOUR LINE
SOIL SAMPLE G - WATER LINE
134.66
90.0
EXISTING TREE LINE
- --- � - � � " GENERAL NOTES SOIL TEST DATA
PROPOSED LANDSCAPE TIMBERS
"0 51.3' 94.0 ALL ORGANIC MATERIAL MUST BE REMOVED FROM THE
AREA DIRECTLY UNDER AND BEYOND THE PROPOSED
94 96.0 LEACHING FACILITY. THIS AREA MUST BE BACKFILLED
I f TO ELEVATIONS INDICATED ON THESE PLANS WITH COARSE TEST PREFORMED BY: JORGE DeSOUSA
gZ1,0 ---- �------ - 97 WASHED SAND OR CLEAN BANK RUN GRAVEL FREE OF
I BECK ,� EXISTING LEACH PIT TO BE REMOVED FINES AND HAVING A PERCOLATION RATE OF 2 MIN. PER TEST WITNESSED BY: SAM WHITE. BARNSTABLE B.O.H.
N 96.0 - - -- - - -- -- - �A � x�� , INCH OR LESS BEFORE OR AFTER PLACEMENT. DATE PREFORMED: 9/18/2003
10.7
I+ { _ �30.0 ALL STONE MUST BE DOUBLE WASHED AND FREE FROM 1
EXISTING - FINES AND ANY ORGANIC MATERIAL AND MUST HAVE LESS DEEP HOLE N0.
LOT 20 XIS T ING THREE / PROPOSED 2 - 500 GAL.-LEACHING LEACHING CHAMBERS WITH 4 FEET OF STONE
(3) BEDROOM --'ter THAN 0.2 PERCENT MATERIAL FINER THAN A NUMBER 200 0 �,�
S i �' TP SIEVE. 5
L
RE��fDEi�TAL _ _ _ FILL
HGiv1E _ _ ��0 N/F L.INEHAN HEAVY MACHINARY SHALL NOT BE PERMITTED TO PASS SANDY LOAM 1410 2 "
ROB GN - - - OVER THE LEACHING FACILITY. 16
-�- '`_ 00 SANDY LOAM ,+
10`1 a �- 10 i TIGHT JOINT PIPING TO CONSIST OF POLYVINYL CHLORIDE 21
< � ` , I N PIPE (P.V.C.) SCHEDULE 40, UNLESS OTHERWISE NOTED. MEDIUM SAND
45
T .Q 104 N 36„
a I MAP 164
1
W LOT 001 I+ FOR PROPER PERFORMANCE, THE SEPTICD SHOULD TOT AE "40
INSPECTED AT LEAST ONCF A YFAR
_ti_...� v,..i ,_v ii-v n i I.`..-....� vi�i vi.. .-� .-si riJ Yvi iwiv ii 1� i V i..�
I 16,865 S.F. DEPTH OF SCUM AND SOILS EXCEEDS 1/3 THE LIQUID MEDIUM SAND
j USE EXISTING 1000 GAL. SEPTIC TANK DEPTH OF THE TANK, THE TANK SHOULD BE PUMPED. CLASS "C"
108.0 ALL DISTURBED AREAS ARE TO BE LOAMED, SEEDED AND
` EXISTING TREE LINE MAINTAINED TO PREVENT EROSION.
11 C.0 �-- I--- _ _� _ �. -- -- 11.0.0 THE GENERAL CONTACTOR IS TO BE RESPONSIBLE FOR ALL „
! HORIZONTAL AND VERTICAL CONTROL OF ALL COMPONENTS. 120
-�-141.03' GARBAGE DISPOSAL SYSTEM IS NOT TO BE CONNECTED TO
THE DISPOSAL SYSTEM. ELEV 101.00
THE DESIGNER HAS NOT BEEN RETAINED• BY THE CLIENT TO WATER NONE 120.0"
CONSTRUCT OR SUPERVISE THE CONSTRUCTION OF THE REFUSAL NONE
B.M. SEPTIC TANK OUTLET PIPE INVERT MAIN STREET SYSTEM. THE CONTRACTOR IS REPONSIBLE FOR MAKING GROUNDWATER ADJUSTMENT (CAPE COD COMMISSION)
B.M. = ELEV. 96.66 ARRANGEMENTS FOR INSPECTION OF INSTALLATION OF THE ESTIMATED SEASONAL HIGH WATER - 15,1 FT BELOW
SYSTEM WITH THE TOWN OF BARNSTABLE BOARD OF HEALTH, BOTTOM OF TEST PIT
THIS PLAN HAS BEEN PREPARED SPECIFICALLY AS A SEPTIC PERC TEST DEPTH RATE
SYSTEM DESIGN PLAN AND IS NOT TO BE USED TO HOLE #1 2 MIN./INCH
ESTABLISH PROPERTY LINES OR BUILDING SETBACKS.
PROPERTY LINES AND BUILDING LOCATIONS ARE GRAPHIC
ONLY, PROPERTY LINES NOT HAVING BEEN FIELD VERIFIED.
GRAPHIC SCALE NO REPRESENTATION OR CERTIFICATION AS TO THE
20 0 10 20 40 so ACCURACY OF THOSE SHOWN IS IMPLIED OR INTENDED.
REVISED: OCTOBER 12,-2003 Designed by: GDC_ --
I
' ( DESIGN CALCULATIONS IN FEET ) REVISED: OCTOBER 5, 2003 Drawn by; GDC
1 inch 20 ft.
DATE: SEPTEMBER 24, 2003 SCALE 1" = 20'
TYPE OF BUILDING RESIDENTIAL DWELLING
NO. OF BEDROOMS 3
GARBAGE GRINDER ALLOWED �I Q_ CANNON ENGINEER1NG
LOCUS PLAN _
SEPTIC TANK VOLUME- 1500 GAL. > (2 X 4 X 110 GAL/DAY)
PLAN
REFERENCE----- .. DESIGN PERC. RATE 2 MIN./IN. 11 BRENRAE DRIVE
DESIGN FLOW X 110 GPD/BEDROOM = 330 GPD MIDDLEBORO, MA
oQ
LEACHING CAPACITY PROVIDED:
SIDEWALLS (25.0'+13.17') X 2SIDES X 2' X .74GPD/S.F,= 114.55 GPD ( 508) 946 - 8886
.j MORTGAGE INSPECTION PLAN BOTTOM (25.0 x 13.17') X .74GPD/S.F.= 243.64 GPD
4? TOTAL 114.55 GPD + 243.64 GPD = 358.19 GPD
Q
438 MAIN STREET, BARNSTABLE, MA USE 2 - 500 GAL. LEACHING CHAMBERS WITH 4 FT OF STONE PROPOSED SUBSURFACE
a BY DESLAURIERS & ASSOCIATES, INC. TOTAL LEACHING RATE 358.19 GAL./DAY > 330 GPD
FOR DAVID W. & JENNIFER E. KACHAJIAN SEWAGE DISPOSAL PLAN
MAP 164, LOT 001
MAIN STREET
BOARD OF HEALTH 'USE ONLY 438 MAIN STREET
• SITE � •
OSTERVILLE, MA 02655
APPLICANT:
DAVID W. & JENNIFER E. KACHAJIAN
438 MAIN STREET
OSTERVILLE, MA 02655