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0461 MAIN STREET (OST.) - Health
461 Main Street � Osterville - µ ' flWI�T 4 ':$WtAMN RNSTABLE YiLLA 'ASSESSoR' i1►fAP ac;L 3NSTA�.T.Eg'�:�tAiv�d�P�iaidE�o s�rcc TANK��� � o 1 egg (suel J Oy `s. I33AC�IING FACII:i'11t•fty ) C�" °�'y` h jro og.BEDfLooMs: tow, o "ovsr- M. M.ITDATE COMPLt�IdCE T1A' ' Saparsitan Dcstance Between Eitc Feot l�laacumum Adisted Groundwater Tahle to the Battam of l.&d log.Faci{ity Pr�Yace Waiet; uppi3r1ell andleactting F�aluy (€f any�r Feet oa stta or cin�thtn?AO feet o€leacbng f ) Edge o€Wetland and Leaching Faal�ty(Lf ariy wetlands exist Feet wid"30.0 tee leaching fact � r OP f � - I I 1 CO V e ^ � t 7 Commonwealth of Massachusetts ;,, ' � —bf$�- � 5t, ,w Title 5 Official .Inspection- Form a i,01 Subsurface Sewage Disposal System Form:-Not for Voluntary Assessments _ r S. 461 Main St s Property Address Ed Breslow Owner Owner's Name information is +� required for ever Osterville MA 02655 5-5-2019, 9 y page. City/Town z 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. A. Inspector Information 514 13492-1 Shawn Mcelroy Name of Inspector ` Upper Cape Septic Services` : :t j i - _ €, Company Name P.O. Box•73 , Company Address E. Falmouth '. ' MA`: :02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone'Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with.Section 16.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed above;the information reported belowyis true, accurate and complete as of the time of my inspection; and a ` r the inspection was performed based on my training and experience in the proper function and maintenance'of on-site sewage disposal systems:After conducting this inspection I have determined that the system: 1. ® Passes ` +, x + 2. ❑ Conditionally Passes, i 3. ,❑+ Needs Further Evaluation by the Local Approving;Authority 4. ❑ Fails 5-5-19 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 1 c Commonwealth of Massachusetts 3� Title 5 Official Inspection Form . i I Subsurface Sewage Disposal System Form Not for Voluntary Assessments ' 9 p Y rY 461 Main St Property Address Ed Breslow Owner Owner's Name information is required for every Osteryille MA 02655 5=5-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes:.` ® I have not found any information which indicates that any of the failure criteria described In 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. � 9 g 9 { 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 ears old*or the septic tank whether metal or not is structural) P Y P ( ) Y 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 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 r Commonwealth of Massachusetts : •> _ - , Title 5 Official Inspection Forme If I hi' Subsurface Sewa e;Dis osal System Form,;Not for Voluntary Assessments •4 ' 9 p Y ry 461 Main .a Property Address Ed Breslow Owner Owner's Name information is required for every Osterville -. MA 02655 5-5-2019 a ' •' page. City/Town _ - State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Punp Chamber pumps/alarms not operational. System will pass with Board of Health approval if - pumps/alarms are repaired.' ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will ass ins ection if with approval of Board of Health):. - El-P P ( PP )� ❑•.` broken pipes) are replaced ❑`Y—,❑N °❑AND (Explain below): ❑ r obstruction is removed Y f � ❑ Y - ❑N- ❑3 ND (Explain below): ❑ distribution 66x xis leveled or replaced '❑Y' ❑'N ' -❑ ND (Explain below): • r r ,-1 ❑ 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 ON ❑ ND (Explain below): ❑ obstruction is removed ❑Y El ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health:, ❑ Conditions exist_which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,:safety or the environment.' a. System will pass unless Board of Health determines in accordance with 310 CMR 15.30.1(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 i� Commonwealth of Massachusetts ,111 Title 5 official Inspection Form � M Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 461 Main St Property Address Ed Breslow Owner Owner's Name information is required for every Osterville MA 02655 5-5-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) l., ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each'of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c \ Commonwealth of Massachusetts .A ; Title 5 Official Inspection :Fora i' Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments s >�' �,.� , 461 Main ..at Property Address Ed Breslow Owner Owner's Name information is Osterville MA 02655 5-5-2019• required for every ' page. City/Town - State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) Systerr.,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 TSAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less .,than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ® Any,portion of the SAS; cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or ` ® tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply ❑ - ®' well. ' ❑ ® Any portion of a cesspool or privy is'within 50 feet of a private water supply well. 0' ® 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 r 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 detemiined that one or more of the above failure criteria exist as described in 316 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 1C°,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 ❑ I❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply . ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Fora I�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 461 Main St Property Address Ed Breslow Owner Owner's Name information is required for every Osterville MA 02655 5-5-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the'system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Wasthe 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. ® E 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 f Commonwealth of Massachusetts pt; Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form-Not for,Voluntary Assessments R ft - >"f 461 Main St - Property Address �.4 Ed Breslow Owner Owner's Name information is required for every Cisterville 1 MA 02655 5-5-2019 page. City/Town State Zip Code Date of Inspection D. System Information 1 7 1. Residential Flow Conditions: Number'of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flowbased on 31.0 CMR 15.203 (for.example: 110 gpd,x#of bedrooms): 550 r Description: Number of current residents: 2 . Does residence have a garbage grinder? x, ® 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, El Yes ® No information in this report.) ' Laundry system inspected? ❑ Yes ® No Seasonall use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: r Sump pump? El Yes ® No Last date of occupancy: 5-2019 ' Date y t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 a Commonwealth of Massachusetts Title 5 Official Inspection Form Y ,I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �.� 461 Main St Property Address Ed Breslow Owner Owner's Name information is required for every Osterville MA 02655 5-5-2019 page. City/Town' State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ' ' ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): i 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts . Title 5 Official Inspection Form I w" Subsurface Sewage Disposal System Form-Not for•Voluntary Assessments 461 Main St Property Address Ed Breslow Owner Owner's Name information is required for every Osterville MA 02655 5-5-2019.E " - page. City/Town a State Zip Code Date of Inspection D. System Information (cont.) I a 4. Type of System: , - ; • , ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ i Overflow cesspool 4, ❑ 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, 0 , •Tight tank.-Attach a•copy of the DEP approval: , ❑ • Other(describe): Approximate'age of all components, date installed (if known) and source of-information: 2001 Were sewage odors detected when arriving at the site? „ , . _ ❑ Yes ® No 5. Building Sewer(locate on site plan): - 3 ;, Depth below grade: �• 30" `feet ' Material of construction: Al ❑ cast iron ® 40 PVC r, '❑ other' (explain)-. Distance from private water supply well or suction line: feet il Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Lt5inp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts 1,� Title 5 official Inspection Form ;�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 461 Main St 1.,•T,y e, Property Address Ed Breslow Owner Owner's Name information is required for every Osterville MA 02655 5-5-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) F 6. Septic Tank (locate on site plan): Depth below grade: 20"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1500 Gal H-20 Dimensions: `+ n Sludge depth: 6 Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 211 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts it ,w Title 5 Official Inspection Form 'i Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments. . fC! 461 Main St t Property Address Ed Breslow " Owner Owner's Nam t information is required for every Osterville :' MA 02655 5-5-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): R . Depth telow grade: : feet Materia of construction: , ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene • ❑ other(explain): Dimensions: Scum th'ckness 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: E Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid lev3ls 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 o=construction: ❑ concre-le ❑Tmetal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I),i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments R� a :1 461 Main St Property Address Ed Breslow Owner Owner's Name information is Osterville MA 02655 5-5-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach co of current pumping contract (required). Is co attached? ❑ Yes ❑ No � PY P P 9 PY 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts : 1� Title 5 Official. Irispection Forte r�► Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments. ^ . 461 Main St Property Address Ed Breslow Owner Owner's Name information is required for every Osterville MA 02655 5-5-2019, page. City/Town State Zip Code Date of Inspection D. System Information (cont.) �{ 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes El No* Alarms in working order: '` ' ' ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of-pumps and appurtenances, etc.): a * 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: 5-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.,7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 l Commonwealth of Massachusetts ra Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 461 Main St Property Address Ed Breslow Owner Owner's Name information is required for every Osterville MA 02655 5-5-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach chambers in good condition and empty at inspection with no visible stain lines. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No it signs of hydraulic failure level of ondin condition of vegetation, Comments (note condition of soil, g y p g, g , etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts pr Title 5 Official Inspection .Form 0;j Subsurface Sewage Disposal System Form Not for Voluntary Assessments, ; 461 Main St -" Property Address Ed Breslow Owner Owner's Name information is Osterville MA 02655 5-5-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): rc Materials of construction: ' Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): { r ' r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of.18 Commonwealth of Massachusetts ,w Title 5 Official Inspection Form ! i-i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 461 Main St Property Address Ed Breslow Owner Owner's Name information is required for every Ostefville MA 02655 5-5-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I . � l ji f 1' t 1 �r 3 � 1 � — h o. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts , ��� Title 5 Official Inspection F rm-to . if Subsurface Sewage Disposal System Form --Not for Voluntary Assessments .a s 461 Main St Property Address Ed Breslow Owner Owner's Name information is required for every Osterville MA 02655 5-5-2019 " page. City/Town + State Zip Code Date of Inspection D. System Information (cont.)'-' �� • r . 15. Site Exam: ❑ Check Slope ❑ Surface water , ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If.checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. 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 i I C Commonwealth of Massachusetts r� ;w Title 5 Official Inspection Form I'll Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 461 Main St Property Address Ed Breslow Owner Owner's Name information is required for every Osterville MA 02655 5-5-2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist . Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: ,For 8: Tight/Holding Tank—Pumping contract attached 'For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached :For 15: Explanation of estimated depth to high groundwater included { a I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 No. ---------� Fee---- ---�T ----------- BOARD OF HEALTH f TOWN OF BARNSTABLE It Applicat ion for Vern Construction Permit Application is hereby made for a permit to Construct ( "f, Alter ( ), or Repair ( )an individual Well at: _4/j1—_ _ l`� — — /� / Location — Address Assessors Map and Parcel �bt/S } Mash co/ Owner / Address SCGov L�c D"cG _"utk Installer — Driller _ Address Type of Building Dwelling __— Other - Type of Building-- ---- No. of Persons-- —_____—__—__ Type of Well �` --__—____ Capacity Purpose of Well Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Ce 'fica of Compliance has been issued by the Board of Health. Signed — O //� v dat('�` Application Approved By — - date Application Disapproved for the following reason ---.--------------- -----___--____—___ date �A!Z)cL --�53 X(ol Permit No. Issued _-- ----_ date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( �I, Altered ( ), or Repaired ( ) by-- J A SCA..,t.me`F- — ---— — --—— -- —6 — Installer at y G ! atti c<<�, S ?� 6 S�?'� l/ has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ----- Dated----- --- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE— Inspector--------------- -_— —____ a 'r IF No. AQ-91, Fees:-- -- BOARD OF HEALTH TOWN OF BARNSTABLE flappCuat ion-for Vell Con5truct ion Permit Application is hereby made for a permit to Construct (vf, Alter ( ), or Repair ( )an individual Well,at: Location — Address Assessors Map and Parcel Owner-- / — — -------_---Address S C G.•v ors L -��6 ,tit --- --- - - — ---- - —_—_--_- -f- Installer — Driller — -- Address Type of Building Dwelling Other - Type of Building-- ---_--- No. of n Type of Well y — — Capacity--------__—T____ Purpose of Well Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Ce ifica of Compliance has been issued by the Board of Health., Signed DZ — Q _ _ date Application Approved By—,-,,,, «' � —_ _ C l date Application Disapproved for the following reason ------ -----_ --_ P date ermit No. — Issued - —— date BOARD OF HEALTH TOWN OF BARNSTABLE C ertif icate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed Altered ( ), or Repaired ( ) Installer at__ y� ( •� �.�� ST. 6ST�i ��IG has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ----------Dated----THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-- Inspector BOARD OF HEALTH TOWN OF BARNSTABLE ell Congtruct ion permit No. �- Fee- --- -- Permission is hereby granted n A ScG to Construct (v), Alter ( ), or Repair ( ) an Individual Well at street as shown n the application for a Well onstruction Permit No.- Dated - -- Board alth V - DATE TGWN 6F BARNSTABLE L(X ATIGiJ o / $ SEWAGE #0700 4 VILLAGE ASSESSOR'S MAP & LOT NSTALLER'S NAME&PHONE NO. Q,CQ !`/s rem SEPTIC TANK CAPACITY / c / LEACHING FACILITY: (type),.5-0o'Ge nV,1,M Cav cS—, (size) /a yc3 NO. OF BEDROOMS BUILDER OR 214� R 1970&/41221 /ek2�oCJ PERMIT DATE: ! COMPLIANCE DATE: S�? 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 39 �s -WT o, A(-7� No. Cam'�' —��/ .; .' Fee r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i fit: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYtcation for Dtopaar *pztem Cow5. tructton Vermtt Application for a Permit to Corstruct(Repair( )Upgrade( )Abandon( ) P'Complete System O Individual Components Location Address or Lot No. L 1M jkl9 Owner's Name,Address and Tel.No. �_=D1Kii12 o 1-_ Gp-Ef-01. / Assessor's Map/Parcel 1(04 ©L5- 2333 60t F of KS`t FI-. Installer's Name,Address,and Tel No. Designer's Name,Address and Tel.No. �219CC Mctll�stC c- �d? v--7WD 12D eAXT£9—,Pl I?F_/ 4 ©St£fi��1��1,>✓ az6S5 $IZ ilm)11N St' ��RaltG-lZ� t`�11 D'Z( S3 S-v E2 Type of Building: Dwelling No.of Bedrooms Lot Size 1.32- sq.ft. Garbage Grinder( ) Other Type of'Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow t I c)xs - S'S© gallons per day. Calculated daily flow SS6 gallons. Plan Date lA- r2_d I Number of sheets I Revision Date ?-7-61 Title lyousc- evrtST2ucne-::)K Size of Septic Tank 1,500 Type of S.A.S. 1.ENCNiN y diALWI Description of Soil e U-- A 4 M1 D 10 1?1Z YA 4e1�- l3'L" P1Bfl l'iN� Srl1J� tiro �i 2 ?�q 1.32� N® wi�tSe -NCPiUi�fT�l� Nature of Re airs or Alterations(Answer when applicabl ,16 W 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 �odednot;t� 1 ce the sy m�1n oFerationn until a Certifi- cate of Compliance has been issued b this B and o Health. �°" Signed - VVC Date Z-l b- o L Application Approved by Date ? Application Disapproved for the following reasons Permit No. 74rV /-0 9�c Date Issued --------------------------------------- n:11 11 ei '4 1.0 1 11 THE COMMONWEALTH-'OF'-' ASSACHUSETTS Entered in computer: M Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplird, tion for Mizpoml *p4tem Con!6truction Permit Application-for a Permit to Construct(Repair Upgrade Abandon YComplete System El Individual Components Location Address or Lot No. q 61 VO ikiA -ST-, Or--rE ev I 1.'Lz. Owner's Name,Address and Tel.No. Assessor's Map/Parcel 164 0 L5, a331 (wo= c)r- PFrr 133 Y-C-11 , 1--L. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. -a? \3 A Wr E 9-,N L?F_/ 4 14 0\\,A G Q S 14 SIL vv%Roq ST. CXS-V_ZY(".F_/ "►t -4 19 - 13 Type of Building: Dwelling No.of 3edrooms Lot Size I -sq.ft. Garbage Grinder Other � Type of Building N,o. of Persons z S V� Showers Cafeteria( Other Fixtures Design Flow i i c)x,-3 5;,50 gallons per day. Calculated daily flow SSO gallons. Plan Date e - 7-o 1 Number of sheets 1 Revision Date Title PeWo-Sec-, o,6se_ Size of Septic Tank I-Too —Type ofS.A.S. Description of Soil 6% A-4 kAAfV__)r 4-1"- IsLo mct> (--lv4r- G. htmt� A(a 4 a 13211 $1 Wn COU N1rJE C> ,Nature of Repairs or Alterations(Answer when applicable PSI ) Date last inspected: Agreement: -Fhe undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system • in accordance with the provisions of Title 5 of the Environmental ode not to lace the PZm_n oreration until a Certifi- d b this B Health. cate oft�pliance has been issue y, is ard o 1 01 • Signed I,:// XW_ Date Z- 16 1 _2 ��Z f2 Application Approved by r�-m do Date _K 2:6y Application Disapproved for the following reasons Permit No._70V 0 9 Date Issued` A ————-- ————————————————————————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERPfY, that the On-site Sewage Disposal System Constructed( 100)Repaired Upgraded Abandoned( )by i at 444 A&n O has been constructed in accordance _Ca V with the provisions of Title 5 and the for Disposal System Construction Permit No. V /-4 9 dated Z - Z-00/ Installer Designer The issuance of this pqrrmtjs_-ial1 not be construed as a guarantee that the system tw functiraze!d. Date Inspector N.. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Miqoal 6 otem Construction Ve mit Permission is hereby granted to Construct Teprair U)grade Abandbn'( System located at /04,(;, and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the fallowing local provisions or special conditions. Provided: b completed within three years of the date of thi ern-ut. C e�/ j Date: Approved by TOWN OF$ARNSTABLE E i LOCATIONi y�` .4 i x 5'�% , SEWAGE.. VILLAGE ASSESSOR 'S MAP & LOT &V-01-5 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type);5V06�'�CHft/��davS� (size) y NO. OF BEDROOMS BUILDER OR OVER CJ . .: PERMIT DATE: � � 3 _ l COMPLIANCE` DATE:. , S , 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 g Facility ( Edge of Wetland and Leaching Facili If any wetlands exist . I ` - within 300 feet of leaching facility) Feet Furnished by 'lt sri � > �i '391, TANS ����7 ay ,Y uTeTTo a� , I �� � - �. V `� V J ,.{: J � � ''f'. V �: r' �.: - ( - --- , Transmittal Letter 1 Board:of Health ' TO: Town Hall` -- - -T i 367'Mal.n Street- Hyannis:-Ma-02-601— Attn: Uohna NVlora•►di From: Stephen A. Wilson, P.E. Subject: P.r,,- Test. Re_.%oi+a Date: d zs joy We are sending you ®Attached ❑Under Separate Cover The following documents: ❑Prints❑Order of Conditions Variance Approval❑Cert.Plot Plan ❑Septic System Permit ❑Other. f 1 \♦/s {1...J{J}l DATE c3y= ; `QUANTITY DESCRIPTION These items are transmitted as checked below: ® For Your Use ® As Requested ® For Your Files ❑ For Review and Comment ❑ For Recording. ❑. For Distribution _ .,..,.,..-Other: Additional Distribution A.-Schy12 . i u- File No. 20oo—`7 Baxter,Nye&Holmgren Inc. Phone: 508-428-9131,ext.13 812 Main Street Fax: 508-428-3750 Osterville,Massachusetts 02655 E-Mail:swilson@jkholmgren.com Transmittal Letterl.doc Town of Barnstable P Department of Health,Safety,and Environmental Services �1ME Public Health Division - Date Q 367 Main Street,Hyannis MA 02601 BARNUABM T20prf0MAS& 1639. Date Scheduled 25, ?enU _ Time fl.co,wr►1 Fee Pd.' i Soil Suitability Assessment for Sewage Disposal ''Performed By: 'S4L ht-t _(A) (Scm Witnessed By: I006ri2. blorik,%d i'J Ito rto c i61 LOCATION &;GENERAL INFORMATION ` Location Address 44 4t„% Owner's Name �a2�.,olr<c �rtshc.r-- �' Q3�1"CrJ� lt.O Y'►'1C\ - f Address Z3�3Ga1�'d1 vNci.iee �.- p - NAssessor's Map/Parcel: y1[a� /�.j Qom/ /S Engineer's Name SiLM Maw A W i l s a,.G?6' NEW CONSTRUCTION f/" REPAIR Tele hone# .J P . 4tr-915,1" t 13 - Land Use Slopes(%) Surface Stones Distances from: Open.Water Body ft Possible Wet Area ft„ :Drinking Water Well ft { Drainage Way ft Property Line ft Other ft SKETCH: (Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) v. \ (. Fi Nil i Prr vfit s.-fit 9 .. 6 HOLtr _�-- JI Parent material(geologic) G(act 2l (�r,4s,no-i-L , Depth to Bedrock Depth to Groundwater: Standing Water.in Hole: "' Weeping from Pit Face r i - Estimated Seasonal High Groundwater DETItMINATtON "O:R SEASONAL HIGH WATET2TABLE . .... Method Used. - Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: . in. Groundwater Adjustment fl. index Well#`_" ,;'%Reading Date Index Well level Arlj.factor __ Adj.Groundwater Level PERCOLATION;TEST DRte /.:2 s a r ,me Na:rt hwu; . �— Observation ; Hole# €' x Time at 9' Depth of Pere, „a', : Time,at 6" >; Start Pre-soak Time @ I I';S S ram _ _ ::_. -Time(9"-V) End Pre-soak Uru 5l2 J" 6� 1< Rate Min,/Inch I t�N RAA1 Site Suitability Assessment: Site Passed_� Site Failed: Additional Testing Needed(Y/N) Original: Public Health,Division Observation Hole Data To Be Completed on Back j Copy: Applicant �_v WEEP C)BSRRVA I ION HOLE LOG Hole # !1 p Depth from Soil Horizon Soil Texture Soil Color Sod Other S Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency. Gravel r `fi o t , „ Es ,, 4. 10 q R 6/4 � � av Q , q .. RVA LOG.. HOLE TIOAEEPOBSE N Hole # Depth from, Soil Horizon Soil Texture Soil Color Soil - 'Consistency, Other Surface(ill.) (USDA) (Munsell) Mottling„ (Structure,Stones,Boulderes. o si tenc %Gravel) pIJEP OBSERUATIO� I�OLIJ LOG Hole# Depth from Soil llonzon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistenc %Gravel i PEEP:OBSERVATION;IIOI:L LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consiste is %Gravel Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes t i,Within 500 year boundary No_4Z Yes 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 area proposed for the soil absorption system?. If not, what is the depth of naturally occurring pervious material? Certification 1 certify that on A ,r;J d a� (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 and experience described in 310 CMR 15.017. a Date Signature � �. 2S0/ 1 DATE:7/3/00_,____ PROPERTY ADDRESS:_,,,4b1 Main —�-tr-g.R ______ ---.9.�q.�5'ZYlI 1 a,rMa c�c------- --_.RZ655---------------- On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1-1500 gallon septic tank. L� 01Jr 2 . 1-Distribution box. 3. 1-1000 gallon precast leaching pit . . Based on my Inspection, I certify the following conditions: 4 . This is a ,_title Five Septic System. ( 78 Co{de ) 5. The septic system is in proper working order, at the present time . 6 . The leaching pit is dry at this time . SIGNATURE: eZlf JOE Name:_,ia,__t4Ssmb.1 r__J_r------- Company: J eeh_P. Macomber_& Son , Inc . Address Box_66 _______ CentervilleL Ma- -._02632-0066 ---------- -- -- Phone: _508 775__3338_______ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY LH P, MACOMBER & SON, INC.Tsnks•Cesspools•Leichfields Pumped & InstilledTown Sewer Connections x 66 Centerville, MA 02632-0066 775.3338 775.6412 RECEIVED 1 t 11 0 8 2000 TOWN OF BARNSTABLE HEALTH DEPT. COMMONWEALTH OF MASSACHUSETTS 1Vj EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENvIR.ONMENTAL PROTECTION ONE WIN'PER STREET, BOSTON MA 02108 (617) 292-6500 TRUDY C Secn ARGEO PAUL CELLUCCI DAVM B. STR Governor Comm' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Addreaa: 461 Main Street N,m.of owner H e r b e r t Wang Osterville ,Mass . 02655 Address of Owner: I QI F.xPtPr 4traat Dateofkupection: 2/3/00 West Ng wton ,Mass . 02165 Name of kupector: (Flees.Print)J O s e n h P. M a c o m D e r J r . I ern a DEP owed system Inspector pursuant to Section 16.340 of Thie 6 (310 CMR 15.000) Company Name: J T.M a c o m b e r & Son Inc . MasTwVAddress: Rox 66 CPntPrvi 11 P Mace 02632 T.Iephone Number: 5 g g 7 7 5 g 3=3 8 CERTIFICATION STATEMENT 1 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 Uupectlon. The Inspection was performed based on my tralning and experience In the proper function and maintenance of on-site sewage disposal systems. The system: Conditlonally Passes Needs Further Evaluation By the Local Approving Authority Fails ,Z kupector's Siflnatwe: Date: d� ✓ Dv The System Inspect shall submit a copy of this Inspection report to the Approving Authority 18oard of Health or DEP)whttin thirty(30) dayr completing this Inspection. If the system Is a shared system or has a design flow of 10,000 gpd or greater,the trupedtor and the system owr shall submit the report to the appropriate regional office of the Department of mvironmsrzd Protection. The original sh"clU,sent to'" system owner.and copies sent to the buyer, If applicable, and the approving authority. . NOTES AND COh1MENTS revised 9/2/98 Pegg lofII A C,Printed on RacKkd Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM:NSPECTION FORM PART A CERTIRCATION(contirwed) Property Address:461 Main Street . Osterville ,Mass . Owner: Herbert Wang Data of Inspection: 2/3/0 0 INSPECTION SUMMARY: Check A, B, C, of A A. SYSTEM PASSES: 1 have not found any information which Indicates that any of the failure conditions described in 310 CMR 1.6.303 exist. Any failure criteria not evaluated are Indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described In the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all Instances. If "not determined',explain why not. The septic tank is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compllanco(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,shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass Inspection if the existing septic tank is replaced with a complying 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 due to a broken,settled or uneven distribution box. The system will pass Inspection If(with approval of the Board of Health). broken pipes)are replaced obstruction is removed distribution box Is levelled or replaced The system required pumpMg•rnore than four~tfines-a yeardue to broken or obstructed pipe(s). Thevystsm w*pass-" Inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 e I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) pr.WyAd&.: 461 Main Street Osterville ,Mass . Owner: Herbert Wang Dace of Inspection:2/3/0 0 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: __AW_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CUR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A FANNER WHICHYMIPRQIECT THE PUBLIC HEALTH AND SAFETY AND.THE EN=OkMENT Cesspool or privy is within 50 feet of 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)DETERmoms THAT THE SYSTEM is FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: - A/'0 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 I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 60 feet of a private water supply well. jW 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 coliform bacteria and volatile organic compounds indicates that the well Is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance cO (approximation not valid).- 3) OTHER AA f revised 9/2/98 Page 3of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTiON FORM PART A CERTIFICATION (contirwed) Property Address: 461 Main Street Osterville ,Mass . Owner: Herbert Wang Date of kw"ction: 2/3/0 0 D. SYSTEM FAILS: 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 15.303. The basis for this determination is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No/ Backup ofeeWage irrtofsciFtyror-sTetem component'dnsto an overloaded omleggedSAS<orcesspool. =.•--.ram 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 ig the s i6ution box above outlet invert due to an overloaded or clogged SAS or cesspool. ' "444ps Cat ' 2 Liquid depth in caseped is less than 6" below Invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Q. Any portion of the Soil Absorption System,cesspool or privy Is below the high groundwater elevation. - Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is-within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less•than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for »col(form bacteria,volatile organic-compounds, ammonia nitrogen-and nitrate nitrogen. - E LARGE SYSTEM FAILS: You must Indicate either"Yes" or"No" to each of the following: The following criteria apply to large systems in addition to the criteria above: Ad 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 following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply _L11 the system•is.-witkin 200 feet•of e-tAbutartr••to-6 surfaoo 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) 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 infor,(nation. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 461 Main Street Osterville ,Mass . Owner: Herbert Wang Data of hspection:2/3/0 0 FLOW CONDITIONS RESIDENTIAL: Design flow: 0 g.p.d./bedr m. Number of bedrooms djsigr};: Number of bedrooms(actual): Total DESIGN flow, Number of current residents: Garbage grinder(yes or no): Laundry(separate system) as orT:_ If yes,sepuatelnspection.required Laundry system Inspected a or no) Seasonal use(yes or no):.* o): Water mater readings,if a ailable(last two year's usage(gpd): � Sump Pump(Yes or no): 74 "dm Last date of occupancy: CO M M ER CIA UIN D U STR IA L: Type of establishment: Design flow:" apd ( Based on 16.203) 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 6 system:(yes or no)� Water meter readings,if available: A/ - Last data of Xupancy- A$ OTHER:(Describe) Last date of occupancy: -P GENERAL INFORMATION PUMPING REC D an rce of forma n /JpN Sd,N 1�"VL System pumped as part of spsction:(yes or no)_,dff l' If yes,volume pumped: gallons Reason for pumping: TYPE Of SYSTEM Septic tank/distribution box/soil absorption system , Single cesspool Overflow cesspool Privy ZU Shared system(yes or no) (if yes,attach previous inspection records,if any) UA Technology etc.Attach copy of up to date operation and maintenance contract Tight TankCopy ofDEP Approval Other W4!¢ M APPROXIATE AGE of all components,date instaged{if known)-and source*fJwformation: — - Sewage odors detected when,arrivingat the site:(yes or no) 110 revised 9/2/98 Page 6of11 P I , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 461 Main Street Osterville , Mass . Owner. Herbert Wang Date of InsWection: 2/3/0 0 Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following: Yes No i Pumping Information was provided by the owner,occupant, or Board of Health. _ .None of the aystemcornpo"nts.kawa. a pua ndJopatleast two•aw*Ww aadAJw aystom basbaeawcetaingrwsal Clow ra rt tes during that period. Large volumes of water have not been Introduced Into the system recently or as pa of this Inspection. 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. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All.system components,Aoclu ding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered,opened, and the Interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: Existing Information. for example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) / 115.302(3)(b)) C _ _ The facility owam.(and.M_p-ote-H different fraauumnarJAu&raprnxidadaw"tafounat ocean tha prnpsi•^+s1nta^-2^ ^f SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART C SYSTEM INFORMATION(continued) Property Address:461 Main Street Osterville ,Mass . Owner: Herbert Wang Date of Inspection: 2/3/0 0 BUILDING SEWER: \ (Locate on site plan) J Depth below grade: 70 Material of construction:NARcast iron Z40 PVC 4%ther(explain) Distance from private water supply well or suction line A4; Diameter All, Comments:(condition of joints,venting,evidence of leakage,-etc.) Joints appear tight No Pvi dpnrP of •I t-nllAnC SEPTIC TANK. �f (locate on site plan) Depth below grade: Material of construction:concretel/&etal-ItFiberglassitkPolyethyleneAAther(explain) If tank is Enetal,list age d&Js.age.confwmed by Certificate of Compliance (Yes/No) 1> 1 A Dimensions: l� �� Sludge depth: _ Distance from top of udge to bottom of outlet tee orflaffle Scum thickness: Distance from top of scum to top of outlet tee or baftle: _� Distance from bottom of scum to bottom of outlet tee r baffle--Zd-e i How dimensions were determined: Comments: (recommendation for pumping,:condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet Invert,structuraFintegrity, evidence of leakage,etc.) P u m Ll_,P n t i r t a n k P v P r v 3 jr n.•s'. s11 e t % 9 I3 t;I e t evidence (locate on site plan) Depth below grade:Material of construction:44 N� oncretelXmetaliberglassA#VPolyethylene4,:gother(explain) Dimensions- - Scum thickness: Distance from top of scum to top of outlet tee or batfle:-.Id)J¢ Distance from bottom of scum to bottom of outlet tea or baffle: Date of last pumping: Comments: r (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level In relation to outlet invert,structural Integrity, evidence of leakage,etc.) Grease revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM NYSPECTION FORM PART C SYSTEM INFORMATION(condnued) Prop"Address: 461 Main Street Ost.erville ,Mass . Owner. Herbert Wang Dsts of Inspection: 2/3/0 0 TIGHT OR HOLDING TANK:��(Tank must be pumped prior to, or at time of, Inspection) (locate on site plan) Depth below grade: W Material of construction concrete Ametal.oFiberglasat�PolyethyleneN other(explain) Dimensions: Capacity AAY gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes/1L�, NoA,* Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) Tight or holding tsnkG era not precant DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet Invert: �® Comments: (note-If level and distribution is equal, evidenoe of solids carryover, evidence of leakage Into or out of box, etc.) Di -,trihiitinn hay hac nna lateral Nn nvirlonre of colirlc rf the box. PUMP CHAMBER-__/4 L? (locate on site plan) Pumps in working order:(Yes or No) Alarms In working order(Yes or No)�w Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Pjimn rhnmhar icy not nracaAr I , revised 9/2/98 Page 8of11 I I ' SUBSURFACE SEWAGE Dlt:: '. t SYSTEM INSPECTION FORM TC SYSTEM INFC.:;.'.:i lON (continued) Property Address: 461 Main Street Osterville ,Mass . Owner: Herbert Wang Darts of Inspecdon: 2/3 t,'0 0 SOIL ABSORPTION SYSTEM (SAS):,,,z/ (locate on site plan, If possible;excavation not required,location m. _. t oproximated by non-Intrusive methods) If not located, explain: Type: , leaching pits, ncr,5er: leaching chambers, number: leaching galleries number:_ leaching trenches., number, length: leaching fields, number,dimanslons: overflow cesspool, number: Alternative, system: /J )� Name o Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, c::.:; ..:!, condition of vegetation, etc.) T onmy Rnnd to rnarse Paad . Ne s1g-Ps---o# i-s--marillidt . teaching pit is dry . _. CESSPOOLS:Ap.Ue (locate on site plan) Number and configure-Jon: Depth-top of liquid to inlet Invert: Depth of solids layer:_ Depth of scum layer:_ Dimensions of cesspool: Materials of construct on:_ Indication of groundwater: Inflow(cesspool must be pumped as part of Inspect.lonl_•_..,__..____ CPR -i n n' R bi T-e-_a_�0 t- p-_j@ S o n t Comments: (note condition of soil, suns.of hydraulic failurs,.level of ponding, cc.-- of,vegetation, etc.) +•- Cesspools ar_e._ not IrPGPnr _ PRIVY:AMC, (locate on site plan) ,(J Materials of construction:— ��7 Dimensions: Depth of solids:L j" Comments: (note condition of soi:. si .-,s of hydraulic failure,level of ponding, c..:.... ..: of vegetation;etc.) Pri vy i R nnt_prAgent _.._ revised 9/2., SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propmtyaddress: 461 Main Street Osterville ,Mass . Owner: Herbert Wang Dau of Inspection:2/3/0 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes Into house) • Y i r V � � t revised 9/2/98 Page 10 of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop"Add.ea: 461 Main Street Osterville , Mass . Owner: Herbert Wang Dot,of Inspection:2/3/0 0 NRCS Report name Soll Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope. Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please Indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site(Abutting pr pertp observation hole,basemeat sump etc.) �etermined from local conditions Checked with local Board of health Checked FEMA Maps yChecked pumping records _zchecked local excavators,Installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map . Gahrty & Miller Model 12/16/94 p+ revised 9/2/98 Page 11of11 •..wnTT rn1Tr1T' RraA•ntR T'Tna+nrll.nrnT.++.t.Iwf.�.w.n nTra�+rnl7T�nl�+ TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION •••Tt•1-T•••:'t—T.tIR-.T1TTP.'1.1'n.1'IT\TIR.IT1^"nTT.��.11.••1VIT�i.Rt11—TA11A0111�IT�nl1�A An. •Tf`T•►�1r .-..A -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 461 Main Street Osterville , Mass . ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Herbert Wang PART D - CERTIFICATION NAME OF INSPECTOR Joseph P .Macomber Jr . , COMPANY NAME J• P• Macomber & Sgcln' Inc . COMPANY ADDRESS Box 66 Centerville , Mass . 02632 Street Town or CSty state LIP COMPANY TELEPHONE ( 508 1 775 - 3338 FAX ( 508 1 790 - 1578 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 omplete 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 maintenance of on- site sewage disposal systems . Chzck,,ne:steui PASSED ' The inspection which I have conducted has 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 , System FAILED* The inspection which I have can cted has found that the system fails to protect the public healLh and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector 'Signature { Date ecopy of this c rtification must be provided to the OWNER, the BUYER Own here applicable ) and the 130ARD OF HEALTII. * If the inspection FAILED , th'a owner orho' orator shall u p pgrade ' the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CHR 16 , 306 , partd .doc Fee--- ----- ---------No. ------ BOARD OF HEALTH TOWN OF BARNSTABLE Application, for Veil Constructionpermit Application is hereby made for a permit to Construct (vr Alter ( ), or Repair LI)an individual Well at: -------------------------- ------- Locatior — Address Assessors Map and Parcel (t------------------------ --------- -- ------------ C wner /� q// Address ` - — —---- — — ----------- --- -- ------=-------- Installe- — Driller Address Type of Building Dwelling------------------------------------------------------ Other - Type of building - No. of Persons--------------------------____—_____________ Type of Well- - - D ----- Capacity - - -- -- - --— — Purpose of Well---- �� -1_-=y------ ------ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Sign. - - - - - _ 01.1—rz -- date Application Approved By date -___---- Application Disapproved for the following reaso ------------------------------------------------------ ----------- ----------------------------------------------- date WVq Permit No. -- Issued----- -- - ---- ---— ---- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of (Compliance THIS IS TO CERTIFY, TZat the Individual Well Constructed ( 01, Altered ( ), or Repaired ( ) by------ Installer at--- T. /G has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -----------Dated----THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---- - - Inspector-----------____� —_ �.,*"'.�.� _._-..� ..�.. .i4 ..`..._. _±.�-i - _ _,- �+..,,p_ e;Z' w .. •1 Ia-.c- . i .-� .._ ... .... ...n. _ „a-- --._ Fee-- ------ --------- 'BOARD OF HEALTH TOWN - OF _ BARNSTABLE zippticationArVill Congtrutt ion Permit Application is hereby made for,aSpermit to Construct$(r.�' Alter (- �; o .Repair an Individual Well at: .tocaho� '-Address. - v. '�!,;'Assessors Map and Parcel; -M-/ --- 5 /fro��="' - ------- -- fit-- a, 5-7- --0-SXC�V��� -- - - Owner Address' Q_A SCG•vim-�l - - - -- ----= - -- °:_��-- `�G�----r'-=��5��' �- r''� - Installer — Driller Address . Type of Building Dwelling-------------------------------------------------------- Other - Type of 3uilding --- ---------- ---- No. of Persons — - - --------- -—---- Type of Well L yP ----- -- - Capacity-- - - - --—--- - ---— Purpose of Well ��✓,�z /ate, -=°' -���---- Agreement The'undersigned agrees to insEa11 the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operatio_Z until'a Certificate .of Compliance has been issued by the Board of Health. Signe - -- - ---- - 3� f -------- date Application Approved By _�� - - - - .-• — -- -date' Application Disapproved for the following reaso -------=---------------------------------------- ----— K=4 den ---- ----- ----—--------------- date W Permit No. q_.. -- Issued—_- - - ----- --- =---- date . •sSLlla! 34i4i�i4ilm140e'r86SRf'J�4iOb®fOeti4f4'+4�TiQo4o9eRol6tili�i4e0a9iBdwilflblfOfAft64f AflWef�hf@i050iBf9ti43!!i!IKSMlG1F4a?Rf4aRi!4flrP4wi0i.tf6i4G9ii64plf/i'!WF4i!iTvti!'n'•�m BOARD OF HEALTH TOWN OF BARNSTABLE C ertif irate®f' Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ey Altered ( ), or Repaired ( ) by __O Y� ✓U,yw,P-�� Installer - ------ — --- at- -- __ -_-— --- --has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -------------Dated---- ---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL.FUNCTION SATISFACTORY. DATE- ---- .=— _ Inspector-- ---- -- --- ------—- >i4 iQiT�'i@itiRi!iifpf481TiWliKfGHNfill.4fEe4aNfiWGlal4s'dgi4f L.Y_i4flemiei!fief4i4G?►4iYf4fBs4ipwieiK46i�Y1 W 4i2+i!i!V!a!e.lili!i!ia^!i N 4f9i4i!Jpa 4i!sri•�G!a!i9 a�sRii!i+s?i!a¢ BOARD OF HEALTH TOWN OF BARNSTABLE . �-- well �on$truttion�erittit No. -- - — Fee- - ---- Permission is hereby granted DA to Construct ( t,, Alter ( ), or Repair,( ) an Individual Wel at: --------------- Street - - - - as sho on) phicatip for-a Well Construction Permit .-- No.- -- - Dated -- ___— - = - ----------------------- Board of Health - DATE LO C-A tION SEWAGE PERMIT NO`�/, VILLAGE INST LER'S 'NAME �& ADDRESS B UILD OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED ,7c- I I _� �.�,'� �� -._. ,�. c'� --- — ,� . � � , ; ;�, a Herbert Wang 461 Main Street Oslerville ,Mass . 02655 1-1500 gallon septic tank. 1-1000 gallon L. P . 1-Distribution box . I . �.»R' ,, � � . , L� 4. � � ��� ��/� I i \�� 1 � / \ �(�j' � i � � �� S��\ � 'd �(�� ��� �. Q�-v�1�� d � _..�."t..... FEs.........J..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEA TH ................ ; ......0..............P.... .. . .... .................. Appliration for Disposal Works Tnntrnrttun Famit plication is herebi made for a Permit to Construct ( v) or Repair ( ) an Individual Sewage Disposal ystem\at ...... 1. /..... _.... ............................................................. ...... ...................................•---- ... -. cc ati n-Address Owner Address W ¢1.2"I . -•--`...= .' ...-="'........................................ ................:......•--•-••----............................................................... ess Type of Building Installer SizerLot............................Sq. feel Dwelling—No. of Bedrooms.___.___..��_________________________Expansion Attic ( ) Garbage Grinder ( ) d YP gI '4 Other—Type T e of Building No. of persons............................ Showers — Cafeteria w YP g P ( ) ( ) d Other fixtures --•------••---•----•-----•---•---- �.E'eas --------------•------------------------- ------------------•-------------------------------••- W Design Flow_----.Z.1-:®-------------------------9Acons gas Per�se��r day. Total daily flow.............................................gallons. WSeptic Tank-Liquid capacite_ Length..�....... Width....X._..`...._ Diameter________________ llepth '___.._.. x Disposal Trench—No. ................... Width____...._..._____._ Total Length.................... _-�_�/! r.. Total leaching area.................... ft. Seepage Pit No.---./------------- Diameter...��%- _. Depth below 1 let._._;; _______ Total leaching area , .sq. ft. z Other Distribution box ( � Dosing tank ( ) O N �' 7? Percolation Test Results Performed b �dteV.......... . .. ... ........... Date. _..._. . 0-4 n, aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to groun wat ........................ w Test Pit No. 2...............minutes per inch Depth of Test Pit.................... Depth to ground water........................ A+' _ ---------•--- -----------•-•---------......................._.....--------.... . p ......... r Description of Soil-•--_-•�r'_�_P__- �.tl---- ---- -------- � ----- •mil-9�'��•� •------ -� ;- 14 W ......................-..............................................-----------------------••----------------------------------------------------....---------------------------------------------. UNature of Repairs or Alterations—Answer when applicable............................................................................................... •-------•---------------------------------••--•-•-•......................-........:.................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT?:; 5 of the State Sanitary Code—'The undersigned further agrees not to place the system in operation until a Certifica-e of Compliance has been issued by the board of health. Signed-eft...-• ---------------------------------------------------------------------- ------•--•-•-•--...------------- ,�'I Date Application Approved B�.._..= JA"' ' /�` l° !1 = �� ....... .... Date Application Disapproved )or the following reasons:......................................................:`...................................................... -------------------------------------••.....---------------------------•-•----•....-••-•--------...--•----------.....--------•---•---------------•••----•-•--------------=•-•----•----•--••---....----- Date PermitNo......................................................... Issued_....................................................... Date r No........f _ ............................. THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD O . HEA TH ........ _..... . .�......OF............. .. ........................ ............___-- ; Appliratiun for Disposal Works Tonstratr#ion jhrmit Application is hereby made for f a Permit to Construct .(4,--)or Repair ( ) an Individual Sewage Disposal System at y Lacatkon-Address or Lot No. ...................... ........ �. � -.5,'`. ,iT'""• .r'�+R-7 , tam. i if7' ./' ! "_..........�.+.'.'i�C«C7 Cw'�i�v'„G:.s/•»-y� Owner Address ........................................ .....__....._._......••••....•••--...--•-•--••..............-••-...........-------•--..........••. Installer Address Type of Building Size Lot............................Sq. feet _4". Dwelling—No. of Bedrooms......... �__________________________Expansion Attic ( ) Garbage Grinder (�� p4 l Other—Type of Euilding ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a :} Other fixt-.ires --------------•--•-•---•------... de �,rpa�.•----------------------•---.------------------ •-.,------••••••------------------- W Design Flow..... ___...___».....�,z allons per.person per day. Total daily flow.............................................� gallons. WSeptic Tank—Liquid ca.pacity_`,-_.__gallons Length____•_-"' Width__. Diameter________________ Depth,± ........... x Disposal Trench—No_ ____________________ Width_.____.._.,.....___ Total Length.................... Total leaching area........ ........... _.....sq. ft. Seepage Pit No._._/-__. ___._._. Diameter._..'PPt _._ Depth below ir��}let•.4 �..+ Total leachingarea_?��'�° � ,,.- P U A �� � �j'" 7� --�......sq. ft. Z Other Distribution box (tom`) Dosing tank ( ) f '-1 Percolation Test Results Performed b . ' s= :.__ ''ft?�' -_._ ___________. � 0 /✓, __.___.__.. y yr ;: Date ,,.�-_..--- Test Pit No. I......._.......minutes per inch Depth of Test Pit____________________ Depth to grou water_.___._____.____..._.__. (i Test Pit No. 2...............minutes per inch Depth of Test Pit...........:,........ Depth to ground water........................ Description of Soil_...._m =s=- r 'Y!°YZ-----...... h - r: ' a .�, , .�.,. ------------------------------------------------------------- W ••--•----•---------------------------•-------•--•---•------•--------..--.---•-------•--•••---•-----------•-----•---•-•----•---=------------...------------------------------------------._...........--- UNature of Repairs or A1=erations—Answer when applicable______::.,N..............................._______............................................... . ti .. ______________________________________________________________________________....___................._........_.__.___________.__._..___._._____________..___.._______._.__ .............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT?., 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed -=•- ••-•--•---..••-------•-•-•••-••--•••......••........................... ............Da e...........•. By Application Approved Y----------------------- ...... •.Date Application Disapproved for the following reasons----------------------»____-___._.......___________.___...__...._.____________________-•---- -------•-.... .........................................._.............................................................-----•----------------------------------------------------------------------•--•---•-•-•--:--•- Date ,r PermitNo......................................................... Issued.................................................•..... Date "X THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1.........OF........... �441cwla.. ............................. Tprtifiratr of ToanpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (1_-�or Repaired ( ) by _... -•• ------- ----•- Lf �1 InsydZ ...... at.`,_ , . ........... _.Z/..... ................................................ has been installed in acccrdan with the provisions of T 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.___ ___""___._j!�_1_»_____»_. dated_..... �..�- 70 THE ISSUANCE OF THIS•-CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.' DATE................................................................•--•-•---•-•--•• Inspector...................................................................................... THE COMMONWEALTH OF MASSACHUSETTS _ f BQ�1RD F HEA T .. f / t/ 7 :L........OF..... A .Z rJ^rV No.. ..................... FEE........r. -~' Disposal Vorks Ton ruction rrntit Perm> Sion is hereby granted................ ... .......... •• >--- ..............................•----- .........,:.............. i • sposal Systemto Cons ctyr ReDai an In iv�ual Sevag at No.. ••••- �X ... r Street d Q' as shown on the application for Disposal Works Construction Permit No........... _____ ated... _ _!.:_ .:___..:.. f b ..........................�___.....____ ..... ........ _.... 1 �� �� oard.of Health DATE::. _ FORM 1255 HOBBS-& WARREN. INC.. PUBLISHERS - - _u J. . o ,ate �I►;I�ci� a ....y oiI �■m�� �� z �1i,� �L o �D mill 1 1111 IMIll ,\ \ mmillm h6l,� 0 ?'a'► ':�r_ ._.__ _-,err—__ vT• ' J BRESLOW RESIDENCE / 464 MA11 STREET OSTERILA-M MA 02649 I \ GENERAL NOTE& \ N M -613 n-- r-. ---------- COiFEEos _ \ 207 BEODRM 4 OOK � � � /'© � }} BOOM 1 MASTER BATH a;Mca. .O°.ram... _ 3 r I I �ATH\ I BEDROOM I22- I I 1 � I i - CLO a 9kT+1 ---- LA c - SET N re • :20Lrli-/ a= 1 - I I I i i I B I RTE7\\n -_- LIVING !r( 1 ! \\ : I \\ .i I 1 \\ zr z1a i \\ I ! r \ HALL AY L __ r• \ r M Ar N O STAIRi DOREVE NICHOL.AEFF \ t ° rr wr rr p r-ap \ .b \ BATH \\ \ BEDROOM ®!! ` PRO..ECT NIAMDER: 5012 i } \\ DRAMM 6Y:.JAD ® r %Cs a.NOTED DATE:PSSPLUARY 14,2001 c �20 ® I I R-�VI910N9 DATE T=TLE j I I SECOND FL00R PLAN �4 .G4 SECOND FLOOR PLAN BRESLOW / �•x RESIDENCE, 461 MA21 STREET 03TERVLLE.MA 02649 u , I •\\ �• -'� ,.. _.. '/jai YvC`d•\ I r-- i GEMERAL NOTE.& I _ I, 1 I 1 / I 1 / n -- -- ' // ��1 / \1 I 1 I \ ' / ' � 1 ❑ Ill----1 . , , \\` 1 �/ \ 11 �-• 1/ I I ® 111 I I � p I ' I j. rA J / � I I r , \ / •� 4w 9 4w O � t � 1 DOREVENICHOLAEFF ` .V�IDLTIIG CKI / r.r `.OrCE , / I / •-C t 4 ' PRC.HCT AMBER: SOU DRA%Wh Dr.,,AD 3CAL.E:MOTED . DATE:PEGRUARY b.2CG1 REWIOn3 DATE SiMR ------- ------='--- -- TITLE TH 0 FLCCR/ROOP PLAM I 1 >r Wins.ur ( 1 1 I , ----------------- wa ROOF FLAN/ THIRD FLOOR PLAN su�c yr.•c CAP i f BRESLOW f j RESIDENCE i 464 MAW STREET iOSTERVL.L.E.MA 02649 i GENERAL.MOTES: I /' UNPNISHEO SASEM NTI MECHANICAL } HOW ATER RECREA ON ROOM `\`\ ' V - STAIR oo. - - oof � n Au ar � ' STAIR -t BATH/SAUNA/STORAGE Ibe., 3 El MACHINE RM - - AMCFUTWrM . VRO.E+CT KJMBER: SO-3 - 1 DRAW"BY: - r SCALE:NOTED DATE:DECEMBER 29.2C00 0 ' R=WfDN3 DATE TITLE BASEMENT 7L.AM A=41 T BASEMENT FLOON FLAN ac _ I z v �N 2 Joshu TYPICAL SYSTEM PROFILE ��, and FINISHED GRADE Wo TOP OF NOT TO SCALE Sam ond U) P FOUND. = 24.69 3 j Z" FINISHED GRADE OVER TANK - 24.0 VENT{ _ N - FINISHED GRADE OVER D. BOX = 24.0 LO FINISHED GRADE OVER LEACHING TRENCH = 24,0 -48"MIN. 3" 4" SCED. 40 PVC (TYPICAL) 4„ SCH. 40 PVC FIRST 2' (TO BE LEVEL) p MAIN ST <ti9�o 6• Him) � 12" (min) Cover O ERVILLE 0L2 min 36" (max) Cover ST 22.5 22.3 1 or 0" CI TEES 2.0 FINISHED CONSTRUCT:ACCESS 21.8 6 SUMP ..: 21.6 4" SCH. 40 PVC 2"L 8"t 1 2" eq� BAY " EAST BASEMENT MANHOLE OVER INLET . . ayer 1/ o / -_ rQ� FLOOR 15.0 TO TANK TO:AT LEAST AS BAFFLE :.:.:.. : :. ;::. Peastone LEACHING CHAMBERS Py R WITHIN 6".FINISH GRA _ 0 0�, REINFORCED CONCRETE .., 6 CRUSHED Slope - 0.005 min oa= Z ;. . STONE BA J,- r FOOTING 4" PVC/ 2J.5 0 0 0 O 0 0 0 0 O 0 0 O 0 0 0 0 0 70 0 0 0 0 0 0 O O O O O O O O O O 101 .10 a 0 Parker Po d BOTTOM ELEV. = 19.5 Crystal Lake Neck Pon - " N 1500 GALLON SEPTIC TANK DISTRIBUTION BOX 5' MIN 70 BE INSTALLED ON A LEVEL STABLE BASE TO BE INSTALLED ON A LEVEL STABLE BASE No Groundwater Observed ® 14.5 CULTEC D RECHARGER 330 I I 3sv�, Baxter, Nye & Holmgren, Inc. BOX FENCE P # 9916 1/12/2001 POOR I ENGINEER BOARD OF CONDITION IN" ,f ,! WILSON HEALTH AGENT . r } I; D. MORANDI �- c' r 1 __. TEST PIT 1 II ' G.S.E. = 25.5 - -.. _ __.-: ._... - .,._-., -..-_ I ' .:. _.._'. _- . _ ...... ... _:-... - .,. .. ,.:. . .. ., .. . - ,. .,.,, -...___ -': l•I IJI(-.- ii_JI 1 11 LVV IIY VI\IVLI,r'\1 , �• � EXCAVATED IN HILL - NO 'A' t' PROPOSED.,STONE ° OR 'B' HORIZON t RETAININ� WALL C1 S of:3 i�. <'.i. ... MEDIUM SAND PROPOSED) 6/4 YR RESERVE 44 TEST PR C2 1 S MEDIUM-FINE SAND r` C-110 _YR 7/4 .001 ' r rj yy r r ! �' 132 NO WATER ENCOUNTERED @ 14.5 PERC @ - 4 OW RB H I RATE 2 MIN/IN Ji .r • " I 2�• F Leaching Area Requirements PROPOSEDroQo a 5 BEDROOMS A7 110 GPD/BEDROOM = 550 GPD f; I ' t)RNE ExJST1NG ' = LEACH PIT - . r I ADDITIONAL 50% FOR GARBAGE DISPOSAL N.A. SH . PERC RATE 2 1 MIN. INCH CLASS 1 : TOWN & STATE f - _: PRDI?'PQSE•D�H�It PROPOSED ' - OF COASTAL • ;>r/ � - -� :... �. TOP / LTAR = 0.74 GPD S.F. l i,. E• ;' �� .. �': BANK CATCH BASIN �/ MINE LEACHING AREA OF S.A.S. PROPOSED a / i COASTAL BANK LEACH PIT ,f ._ 50 OFF` 550 GPD/ 0.74 GPO/S.F. 743 S.F. MIN. PA �• - �, \ • // PROPOSED SYSTEM SIDEWALL 12+44 2 2 _ 224 S.F. =z1 15.0 w F.F. W _ - �, � ' � BOTTOM 12 X 44 - r._ h: ;, ,•, 528 S.F. _ 46 _.. , / / � E TOTAL 752 S.F. � GI.A Jrl._ V 20.e3 � � _ ,> f 1 1.5 WASHED STONE I µ OSED . _ F : .� EL POOL PROPOS D STONE 12 RETAININ WALL ,ollN_� 1 r a APRO P TIO PROPOSED H f. . PR FOR F - _- __ - E 3 , CO .04 nrcor 1 df' PATIO D IV . 0 PLAN OF LEACH CHAMBERS l . NO SCALE _. TOWN�& STATE TOP OF COASTAL ' D ', ,• 5TATE ,+ ST ETA G w . BANK : :B B L E S 1 f ,} , �. E2i`JE b �`;�' WALL N/F 12 ry r C EDGE: f -_ - •-iDo- 11.0 ,' EDWARD & NANCY ESKANDARIAN OVR ..r wk _ FINISHED GRADE • _-.. _ CONS _ - . CEL 004 » „ \\ \\ \\ \\ �\ \\ \\ \\ \\ �\ \\ \\ \ \ C�-- ,' MAP 164 PAR 36 MAX.- 12 MIN. / // // // // // // // // // // // // //\/r COMPACTED FILL i _i i I TREES ,. LOT 19 2 .. PEASTONE \) -' CLEARED AREA L.C. PL• 9843-1 -' WORK UMIT 112 �i/ _ 3 .5 0 3 0 1 LC./ PL 9843—I '', •, DOUBLE cc v. a 2703 SF f �1NETLAND 0.06 Acres t �,. r _ _ WASHED STONE / 56,924 Sr - TOTAL - 1.31 Acres f _._--_ • 54,221 SF UPLAND 1.25 Acres f 100'OFF - i " FLAGGED,-` _/W�ND cC fi��fi SECTION j7�- O At- ,� NO SCALE ��N 0, QFFS� Q RA#2 } , / RA#3 LEACH SYSTEM WITH INFILTRATOR DESIGN TO BE E 4 !,� I :. �;., REMOVED �.nl�'°ra ALL PIPES 70 BE SCHEDULE 40 PVC RA#1 N ���• °r USE 1 4 DISTRIBUTION LINE IN 6 RECHARGER UNITS µ j I IN A 12'X 44' WASHED STONE TRENCH AS SHOWN i EX 50 OFF RA#4 I t;f� �:,.a I FLAGGED i r ca p VEGETATED WETLAND • � �. MAINTAIN ASSOCIATED WITH , WETLAND DELINEATION BY ENSR . EXISTING 5' \fir �;+ SALT MARSH: Q 1 t ( B. V. W. ) f I + :. PATH To ., , �� D. MICHAEL BALL. WETLANDS SCIENTIO RA#5 I oocK FLAGGING DAW_ ► ti oaf,. . FIELD LOCATION MARC 15FEBRUMIY 5�2 ! I BAXTER, WE & HOL.MGREN, C. RA�s WETLAND DELINEATION BY ENSR • WETLANDS SCIENTI �� EL BALL. _ "� f WETLAND ' . MICHA ' FLAGS RA -9 I_ O-- EwsnNc I•la� DECK av: HOT TUB TO BE RATED• ALL 1 _... sE, GGING DATE. FEBRUARY 15, .2000 " BEAC H 15, 2000 t C FIELD LOCATION: MARC - f ._ . . --�- • • -7 � DEBRIS TO 8E REMOVED OF SITE DARTER, NYE &`HOLM L ;(-g,v , I sf t-F - RA#2 R 2- EXISTING SEPTIC SYSTEM TO BE PUMPED REMOVED. i I r RA#2 RA 7 -9 I p C- :5 PATH 2 6 B E A C H ! A# 'I TO DOCK r -J r.>' COASTAL ' BEACH /I ,r 1 • • 461 Main Street I - / M r A. N H 1 :� 1 i Osterville, MA. 02655 _..._ f• - COASTAL ; , VEGETATED WETLAND !,_ -- ASSOCIATED WITH A#2-3 BEACH 3i?L_, a SALT MARSH PREPARED FOR , ._ _.. ._. FIELD L. B , ` - war Breslow WETLAND Z MAR' .7, ---•1KA7#2-2 PROPOSED HOUSE CONSTRUCTION A#9 LINE PROPOSED PHRAGMI 1'§_S CONTROL ! FXI'=Tl�i; F�..C! , TIMBER PIER � PLUG;, ,r hh11 rr i l ..fti15E :i - Baxter, Nye & Holm ren, Inc. rSt ��_,Z,.. , ILE_ v , Y b1 • j Registered Professional . FEL TAKE FND Engineers and Land Surveyors =' 3.85y� EAST BAY o Ma 02655 812 Main Street, sterville, Phone (508) 428-9131 Fax - (508)428-3750 I 0' 20' 40' 60' 4'j 'r r t4< �N OF SCALE. x-20' DATE: October 27, 2000 ,?5, REV. DATE: REMARKS f o w a -i 1 9113100 TREES p w 2 1109101 DRAINAGE EXT U/La0001 ' :�`c �/STE4•��`�ti 3 1116101 MOVE SPA �^ I \ TONAL ma 217101 SEPTIC & T.P. DRAWING NUMBER H. 2000 2000 07 2007PB2.dw 2000-7 � r T� o tovNoA�o �/ -�� Cv J j to 21 E Z 2 --- -- - _ - � �C"C 9 u A'7""r,c../ To �'c E CJr9 Ti o�✓ 7 7C� , Zo o o - --►- - � �-,G�o x- Ta l/F�'�,�Y S�J*✓U G o.�/1.�i?i O,�/ /(r /�oo / SE�Ti G \ y G r lac,✓ �iT � Gxc .9 J.5'T'E i9s.! 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