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HomeMy WebLinkAbout0480 MAIN STREET (OST.) - Health 480 MAIN STREET, ®S'TERVIlLLE A=141-091 '�1 Commonwealth of Massachuse tts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 480 Main Street 'I Property Address W Peter Mulvey w•� Owner Owner's cm r's Name information is Osterville Ma 02656 9/26/2016It required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form..Inspection forms play not be altered{n any way. Please see completeness checklist at the end of the form.. Important:When A. General Information p q filling out fours on the computer, use only the-ab 1 Inspector: key to move your cursor-do not Sean M. Jones- use the return Name of inspector key. 8 M Jones Title V Septic Inspection �y Company Name 74 Beldan Ln. o Centerville Ma 02632 5 City/Town ;.State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522` Telephone.Number License Number B. Certification I certify that l have personally inspected the sewage disposal system at this address and that the information reported below is true;accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section.15.340 of Title 5(310 CMR 15.000).The system: R 1z Passes ❑ Conditionally:Passes ❑ Fails Needs Further Evaluation by the Local Approving Authority 9/26/2016 Inspector's Signature Date. The system inspector shall submit a copy of this inspection`report to the Approving Authority(Board of Health,or DEP)'within 30 days of completing this inspection. If the system is a shared.system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent.to the system owner and copies sent to the buyer, if applicable,and the approving authority. ****This report only 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. t5ins''3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 40 /l/t V 4 Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments. 480 Main Street Property Address Peter Mulvey Owner Owner's Name information is required for every Osterville Ma 02655 9/26/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ®. I have not found any information which indicates that any of failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 480 Main St Osterville is served by a Title V septic system consisting of'a 1500 gallon septic tank, distribution box and 3 500 gallon precast leaching chambers. The system was found to be in proper working condition at the time of.inspection. B) System Conditionally Passes M One or more system components as described in,the".Conditional Pass"section need to be. replaced or repaired. The system, upon completion of the replacementor 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;. El Y Eli N ❑ ND(Explainbelov# 45ins•3H3 Title 5�Wiidal Inspection Fomi:Subsurface Sawage Disposal System•Page 2 of 17 Commonwealth of Massachusetts ; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Main Street Property Address Peter Mulvey Owner Owner's Name information is Osteryille Ma '02655 9/26/2016 required for every page. citylTown State Zip Code Date of Inspection B. Certification (cont.) ! ❑ Pump Chamber pumps/alarms not operational. System will pass with Board.of.Health,approval if pumps/alarms are repaired: B) System Conditionally Passes(cont.):. ❑ Observation of sewage backup or:break out or high"static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board ofHealth): El broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y. ❑ N ❑ ND(Explain below):. ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health). ❑ `broken pipe(s)are replaced ❑ Y ❑. N ❑ ND(Explain below):,. ❑ obstruction is removed ..❑ Y E] N ❑ ND(Explain below):. C) Further Evaluation is Required by the Board.of Health: ;Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health;, safety and the environment: ❑ Cesspool'or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt.marsh t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Main Street Property Address Peter Mulvey Owner Owner's Name information r. Ma 02655: 9/26/2016 required for every Osterville page. City/Town State Zip Code Date of.inspection B. Certification (cont ): 2. System will fail unless the Board of Health Viand Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: Fl The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of;a public water supply. ❑ The system has_ a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more`from a private water supply well**. Method used to determine distance: '*This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal, to or less than 5 ppm,,provided that no other failure criteria are triggered.A-copy of the analysis must be attached to this form. 3: Other: D) System Failure Criteria Applicable to All Systems' You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® 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 El 1z due to an overloaded or clogged SAS'or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded El or clogged SAS'or cesspool ® Liquid depth in cesspool is less than 6°below invert or available volume is less El than 1/day flow t5ins 3113: Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official l'nspection. Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 480 Main Street Property Address Peter Mulvey Owner Owner's Name information is Osterville Ma 02655 9/26/2016 required for every page. CltylTown State Zip Code Date of Inspection B. Certification.(cone.). Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion'of cesspool or privy'is within 100 feet of a surface water.supply or rE] tributary to a surface water supply, ❑ ® Any portion-of a cesspool or privy is within a Zone 1 of a;public well. ❑ ® Any portion.of a.cesspool,or privy,is within 50 feet of a private water supply well. ❑ ® Any portion of a:cesspool:or privy'is less than 100 feet but greater than 50 feet from aprivate 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.2000gpd 10,000gpd. ❑ ® The system fails.l have determined that one or more of the above failure criteria exist as described in 310 CMR:15.303, therefore the system fails. The system owner should contact the Board of Health to determine what.will be necessary to correct the failure. E) Large Systems: To.be considered a large.system.the system must serve afacility with a design flow of 10,000 gpd to 15,000 gpd.. For large'systems;you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ the system is'within 206 feet of a tributary to a surface drinking water supply ❑ the system is located in:a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA).or a mapped Zone_ II of a public water supply well If you,have answered"yes"to any question.in Section E the system is Considered a significant threat, "' r system has failed.The owner or operator of an large •r answered"yes m Section�above the large sy te. a y system considered a significant threat srider Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins.3113 TNe 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Rage,5 of 17 Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Main Street Property Address Peter Mulvey Owner Owner's Name information is Osterville Ma 02655 9/26/2016' required for every page. City(rown State Zip Code Date of inspection C. Checklist "a or"no"as to each of the following: : must indicate" es o Check.if the following.have been done. You u y 9 Yes No Q Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? El Z Has the system received normal flows in the previous two week period?' 0 Have,large volumes of water been introduced to the system recently or as part of this inspection? ® ' 0 Were as built,plans of the system obtained and examined?(If they were not available note as'NIA) ® ❑ 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)] D. System Information Residential.Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actu,al): 4 DESIGN flow based on e310 CMR 15.203(for example:110 gpd x#of bedrooms):9Pd 15ins-313 Title 5 Official Inspection Form:subsurface sewage Disposal System•Page 69117 . Commonwealth of Massachusetts ~� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Main Street Property Address Peter Mulvey Owner Owners Name information is Osterville Ma 02655 9/26/2616 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes :0 No: Is laundry on a separate sewage system?(include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes :M. No Water meter readings, if available(last,2 years.usage(gpd)): Detail` Sump pump? ❑ Yes 0 No unknown Last date of occupancy- Date Commercial/Industrial Flow Conditions:: Type of.Establishment: Design flow(based on 310 CMR 15.203)` Gallons per day{gpd) Basis of design flow(seats/persons/sq.ft., etc): Grease trap.present? ❑ 'Yes ❑ No Industrial waste holding tank present?' ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: f5ins•3113 Title 5 Official Inspeclion Form Subsurface Sewne.Disposal System•Page 7,of 17 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Main Street • Property Address Peter Mulvey Owner Owner's Name information is. required for revery Osterville Ma 02655 9/26/2016 page. CitylTown state Zip Code Date of inspection D. System Information (cont.) Last date of occupancyluse: late` - Other(describe below):. General-lnformation Pumping Records: Source of information: Was system pumped as<-part of the inspection? ❑ Yes 0 No If yes,volume pumped: gallons How was quantity,pumped determined? Reason for pumping: Type of System: Septic tank, distribution-box,soil absorption system Single.cesspool Overflow-cesspool ❑ Privy El 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 11A system by:system operator under.contract El Tight tank.Attach a copy of the DEP approval. El Other(describe): t5ins-Will Title 5 Official Inspection Form:Subsimlaw Sewage Disposai System•Page 8 of 17 Commonwealth of Massachusetts -- - - Title 5 Official Inspection Form "i Subsurface Sewage Disposal System form-Not for Voluntary Assessments b 480 Main Street Property Address Peter Mulvey Owner Owner's Name information is required for every Osteryille Ma 02655 9/26/2016 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of.information: system installed 4/20/1999 per town records Were sewage odors detected when arriving at the site?' ❑ Yes ® 'No Building Sewer(locate on site plan): 4 Depth below grade: feet Material of construction: ❑cast iron Z.40`PVC: ❑other(explain): - Distance from private water supply well.or suction line: feet Comments(on condition of joints,venting,evidence of leakage,.etc.): Joint were ok, no leaks vented through the roof Septic Tank(locate on site plan); Depth below grade: teen Material of construction;, . concrete ❑ metal ❑fiberglass, 0 polyethylene. ❑other(explain) h If tank is metal, list:age: years Is age confirmed by a Certificate`of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1500 gallons Dimensions: 61' Sludge depth: t5ins;3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts --- Title 5 Official Inspection Form Subsurface Sewage<Disposal System Form Not for Voluntary Assessments x 480 Main Street Property Address ' Peter Mulvey Owner. Owner's Name information is required for everyOsterville Ma 02655 9/26/2016 page Cityrrown State Zip Code Date of inspection D. System Information (cont.) Septic Tank cont f Distance from top of sludge to bottom of outlet tee or baffle 3 3" Scum thickness 6 Distance from top of scum to top of outlet.tee or baffle 10it Distance.;from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? opened covers,=took . measurements 3 Comments(on pumping re commendations,.inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, Tank was cleaned at time of inspection.Water level was even with outlet,tank was structurally sound. Inlet and outlet covers are on risers. Grease Trap(locate on site plan): ;Depth below.grade: feet .Material of construction:: ❑concrete ❑metal E fiberglass E polyethylene E other(explain): Dimensions-.- Scum thickness Distance from top of scum to top of outlet tee or baffle. Distance fro m.bottom of scum to bottom-of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y. 480 Main Street Property Address Peter Mulvey Owner Owner's Name information's required for=-:very Osterville Ma 02655 9/26/2016 Page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert;.evidence of leakage,etc.)' Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan)' Depth below grade: Material of construction: Q concrete . ❑ metal ❑fiberglass El polyethylene ❑other(explain): Dimensions: _ Capacity: gallons Design Flow: gallons per day Alarm present: E] Yes ❑ No Alarm level: . Alarm in working order: Q Yes; ❑ No Date of last pumping: Date Comments(condition of alarm and floatswitches, etc:): I , . Attach copy.of current pumping contract(required).is copy attached? ❑ Yes 0 No k5ins,'3/13. Title 5 Official_tnspedion Forth:Subsurface Sewage Disposal System:;Page 11 of 17; - Commonwealth of Massachusetts Title 5 Official Inspection 'Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 480 Main Street Property Address Peter Mulvey Owner Owner's Name information is required for every Osterville Ma 02655 9/26/2016 page. Cityrrown State Zip Code. Date of inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): oilDepth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover; any evidence of leakage into or out of box, etc.): Distribution box was video inspected and found to be in good condition, no rot,water level was even with outlet invert: Pump Chamber(locate on site plan): Pumps in working.order: ElYes ❑ 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. Soil Absorption`System(SAS).(locate on site plan, excavation not required): If SAS not located;,explain why: t5in5:-W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 120117 17 r <C�, Commonwealth of Massachusetts �.i Title 5 Official Inspection Fornn a Subsurface Sewage,Disposal System Form-Not for Voluntary Assessments Y 480 Main Street Property Address Peter Mulvey. - Owner Owners Name information is Osteryille Ma 02655 9/26/2016 required for every page. Ci yfrown State Zip Code Date of Inspection D. .System Information (cont.) Type: Q leaching pits number: leaching chambers. number: 3 El leaching galleries number: Q leaching:trenches` numberjength: Q leaching fields number,dimensions: ❑, overflow cesspool number: El innovative/alternative System Type/name of technology:' Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of. vegetation,etc.): s a s was located but not'excavated due to depth 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 r ction u Materials of const Indication of groundwater inflow ❑ Yes El-No t5hsr W13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments 480 Main Street Property Address Peter Mulvey Owner Owner's Name iicxt is requiredequired for every Osterville Ma 02655 9/26/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont Comments(note condition:of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 45ins•3113 : Title 5,official lnspedion Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 480 Main Street b Property Address Peter Mulvey . Owner Owner's Name informationis required for every Osteryille -Ma 02655 9/26/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the,sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building.Check one ofthaboxes below: Z hand-sketch in the area below . ❑ drawing attached separately 1 L( pfo IV t5ins-.3/13- - Titles Official Inspection Form:Subsurface Sewage pisposal System..Page 15 of 17 Commonwealth of Massachusetts. _ . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , ' 480 Main Street Property Address Peter Mulvey Owner Owner's Name information is required for every Osterville Ma 02655 9/26/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on.record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 480 Main Street Property Address Peter Mulvey Owner Owners Name information is required for every Osterville Ma 02655 9/26/2016 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 l r r Health Complaints 13-Jun-05 Time: 11 i50:00 AM Date: 6/10/2005 Complaint Number: 18176 Referred To: DAVID STANTON Taken By: JUDITH M FLYNN Complaint Type: GENERAL Article X Detail: UNSANITARY CONDITIONS Business Name: Number: 480 Street: MAIN STREET Village: OSTERVILLE Assessors Map_Parcel: 141-091 Complaint Description: MR LAWSON SAYS THAT PINA PICKED UP A DUMPSTER AT THIS LOCATION AND AS A RESULT OF THE MOVE A GREAT DEAL OF WATER WAS DISCHARGEWD FROM THE DUMPSTER -THIS WATER COVERED THE WHOLE STREET AND WAS FAUL SMELLING -THE ENTIRE STREET WAS COVERED WITH THIS SMELLY LIQUID - NOT VERY PLEASANT. CALLED PINA GOT ANS MACHINE. Actions Taken/Results: DS WENT TO SAID LOCATION AND FOUND WHICH HOUSE (ORIGINAL• COMPLAINT SAID CORNER OF MAIN & EVAN.) NO ONE HOME, THERE WAS A RED PINA DUMPSTER IN THE DRIVEWAY, THAT WAS EMPTY. IT APPEARED TO BE A C&D DUMPSTER. NO FOUL ODORS OBSERVED AT SAID LOCATION. PHOTOS ON FILE. NO FURTHER ACTION REQUIRED. Investigation Date: 6/13/2005 Investigation Time: 11:30:00 AM 1 6,s r, 3i DS a '4 c.4vrioN V.0 .� is 1 1 o pis :: 1 'a j K JUN 13 2005 o`.•� `� � eta �' i� DATE :8/1/03------ PROPERTY ADDRESS:480 (lain Staeet _ 0,3teavi e, Na.6e_------- iLll-- off/ 02655 On the above date, I inspected the septic_ system at the abo _� i0/ED Tnis system consists of the loll,owing: 1. 1- 1500 ga e eon .6e/2t.ic .tank. AUG 2 3 2003 2. 1-Di.stai,?ut.ion Sox. 3. 3-500 gaiion Peach.ing cham9eaz. TOWN OFBARNSTABLE Based On my inspection, I certify the following conditions: HEALTHDEPT. 4. 7hiz .iz a t.it.2e Live ze/2t.ic .system. (95 Code) _ :. The aepi is 3y.6tem .ih .in paopea woak.ing olden at the /MeZent time. 6. The chamgenz aae only dame on the Bottom. Ha.s nevea ,peen any h.ighea than th.ie. 7. The ze/2t.ic tank zhouid &e 12umped eve2y 2-3 yeaa.s. SIGNATUR Name - - J__ P__Macomber Jr . ___ Company : jgjtpI, •per_M�rgTt (LI d_ Son, Inc , " cards s :--5Qx_6-I5 ------ --- - - -QRJUDCY.LLLP,_ Na _2Z.632- 0066 Pnone : 508. 775_ 3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY � I IOSEPH P. MACOMBER & SON, INC. Tank s•Ces spool s•Lesch Held s Pumped & Installed Town Sewer Connections P.0 Box 66 Centerville, MA 02632.0066 275.3338 775.6412 • COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:480 (lain S;bteei- 0-3.tenU.i.2.2e, ma,6,6, Owner's Name:Ve znon Boudaeau Owner's Address: Some Date of Inspection: 817103 Name of Inspector: (please print) aoeel2h P. Macom&e2 a/t, Company Name: 1. 1-J. Nacomelelt ff Yon INc. Mailing Address: Box 6 CenteAy.i ie. Na,sz. 02632 Telephone Number: 5 0 8-7 7 5- 3 3 38 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority • Fails Inspector's Signature: /D , Date: . -J d The system inspector shall mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments This report only describes conditions at the time of inspection and under the conditions of use at that 1 time.This inspection does not address how the system will perform in the future under the same or different A conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Pag*2 of 1.1 �, OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 480 11ain Sfaeet e2U.c e, Mazz. Owner: I/e2Izolz ou 2eatL Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS-complete all of Section D System Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The -6g.piic AUAIRm ,iA .in pnnnvn wo1?k,na nnr/on pr_16D 104,2 AQ tt B. System Conditionally Passes: —/o 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. 4 Answer yes, no or not determined(Y,N,ND) in the 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. ND explain: AA 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 obstruction is removed distribution box is leveled or replaced ND explain: „ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 480 Main S bzee.t 0,3te,zv.i.i.Pe, Owner: Ve2rzon RourL�arzri Date of Inspection: C. Further Evaluation is Required by the Board of Health: 416 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 envirorunent. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: A16 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,safety and environment: ,f& 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. VO 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 buL 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other, r 3 Page 4 of g 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:4 80 .Oa-in St2eet e e/I V-ie i e, 0 c--h.. Owner: Ve2non Boudaeau Date of Inspection: 811103 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or /clogged SAS or cesspool _✓ Static liquid level in the distribution box above o tlet i vert due to an overloaded or clogged SAS or cesspool 0, pA I)WS ( '2 . Liquid depth inZ s less than 6"beloWinvert or available volume is less than �4 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped b k1 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. /arty portion of a cesspool or privy is within a Zone 1 of a public well. Katy portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) b(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• 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) yes no � t/the system is within 400 feet of a surface drinking water supply 1/the system is within 200 feet of a tributary to a surface drinking water supply _ V/the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone Il of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. '. 4 'Page 5 of I 1 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 480 Na-in St2eet Owner: Ve2non ualze-au ' Date of Inspection: Check if the following have been done. You must indicate'yes"or"no" as to each of the following: Yes No V Pumping information was provided by the owner, occupant, or Board of Health 1011*'Were any of the system co m one t— Y p n s pumped out in the previous tors two weeks eeks . ✓ _ Has the system rec eived cetved normal flows in the previous two week period? _ ZHave large volumes of water been introduced to the system recent! of Y or as part this inspection ? — Were as built plans of the system obtained and examined?(if they were not available note as N/A) v _ Was the facility or dwelling inspected for signs of sewage back up? �— Was the site inspected for signs of break out? -Z — Were all system components excluding the SAS, located on site? z — Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? Y _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes o Existing information. For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)) • 5 w Page 6 of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 480 Main Staee.t a t eay.c e, ae�. Owner: Veanon Boudlteau Date of Inspection: 811103 " FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x M of bedrooms):��»Uzi Number of current residents:_ A Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system`Syes or no): (if yes separate inspection required) Laundry system inspected(yes or no): g Seasonal use: (yes or no): 40 001=37, 000 ya.�Pon�=101. 37 /�[� Water meter readings, if available(last 2 years usage(gpd) �J Sump pump(yes or no): 2002=5 4, 000 ga-teons-147. 9 5 qPD Last dace of occupancy:T-� COMM ERCIAUINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgR,etc.): AW Grease trap present(yes or no): ell Industrial waste holding tank present(yes or no): Al;f Non-sanitary waste discharged to the Title 5 systfm(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: None ava i�a&2e Was system pumped as part of the inspection(yes or no): _ v If yes, volume pumped: 0 allons-- How was quantity pumped determined? ItA;o Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box, soil absorption system TL Single cesspool Overflow cesspool PrivyAt ` Shared system(yes or no)(if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank ff Attach a copy of the DEP approval Other(describe): 4)lf Approximate age of all components,date installed (if known)and source of information: �. P. Naro;9elz R Son Inc. T a—Pe r/ SU.3tem 4120199 %e2m.if# 99- 194 Were sewage odors detected when arriving at the site(yes or no): A# 6 " Page 7 of 1 I �.. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 480 t7aia Staeet Owner: Ve2non /3oud/ceau Date of Inspection: 811103 BUILDING SEWER(locate on site plan) Depth below grade: V Materials of construction t iron t,40 PVC�other(explain): �t/0 Distance from private water supply well or suction line: !0 l` Comments(on condition of joints, venting, evidence of leakage, etc.): lointe aRRea2 tight. No evidence of eeakarle, The hurtem iz vented thorough the houae ventz, SEPTIC TANK:Z(locate on site plan)l��a1r-i9D.U9 :1 Depth below grade: _ � Material of construction: Yconcrete ?,Y metal"fiberglass.Vpolyethylene 1,16 other(explain) OF - If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):,iO(attach a copy of certDimensions: / 4KZ� �0 M� W , 6^�����y�f Sludge depth: Distance from top O sludge to bottom of outlet tee or baffle: -Aoeot1 Scum thickness:/tdt� Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Inzi-a 0-eed 412019 9 Pe2m.it #9 9- 19 4 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of.leakage, etc.): l l/I/1-D f h o ,t o�2f r f n n,� n ,n ,2 Gig g 4 r n 1)O in nRn rn 7h0 Yank JA /,fn/ir fir nn0 ii --------, P..,—a air nd 6d 1L 4 fb 61 4 Q e ev-idence o/ .leakage; GREASE TRAB4&�Ylocate on site plan) Depth below grade: Material of construction:4kconcrettd.9 metabtd9 fiberglassffJ9polyethyleno00 other (explain): �' Dimensions: Scum thickness: low Distance from top of scum to top of outlet tee or baffle: Distance from bottom of sculn to bottom of outlet tee or baffle: /40 Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): C[2ea6e t za/2 t,3 nni RRD/rOnf'- 7 Page 8 of 1 I �b OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: V�eanson Boudaeau 480 Rain aeet Owner: Li n v ' N a.s.s, Date of inspection: R/1/0 3 TIGHT or HOLDING TAN)a6 (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:&—concrete,4Y metal fiberglass polyethylene t/� V other(explain): Dimensions: ,V Capacity: A09 allons Design Flow: #fi allons/day Alarm present(yes or no): Alarm level: W.4 Alarm in working order(yes or no): .U�9 Date of last pumping: Al Comments(condition of alarm and float switches, etc.): 71ghf nn hoPr/ina IrinkA aAg nol Pae.6ent DISTRIBUTION BOX: ,Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: VO 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.): Di.eta.igut-ioa &ox ha.3 one iateaai. No evidence o� .3oiids caaay n»nn No vvidonro o pal-,age .into oa out of .the Sox PUMP CHAMBERt& (locate on site plan) Pumps in working order(yes or no): IM f Alarms in working order(yes or no):�- Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Pump chain&ea .i.5 not Rae,6en , A ` Pege 9 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 480 1la.in St zeet ,6 t eay.i e, azh. Owner: Veicnon Bouc!2eau Date of Inspection: 8/1/0 3 SOIL ABSORPTION SYSTEM (SAS): locate on site plan,excavation not required) 3-500 oa.PPon Peach.ing chamPe�c.s 33 5 'X13'X2' If SAS not located explain why: Located: See Page 10 f leaching pits, number:� r leaching chambers,number:fi-"!gV 0'6A!'( n ' leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: '6T overflow cesspool, number: /--� X0 innovative/alternative system Type/name of technology:%/7L >'iyP (—,P�1 Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): d to. .ine coazze sand. No .6.i nos o� hydzau-gic. )eai2ulze nn aand.i_ng SO.i.P•5 ate ( luet damRne.s.s in the c am e2.6 Vegetation i.s no2ma.P. CESSPOOLS,4t(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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): ro ��nnnP.s n�v1z O o.6ent PRJFVYC&,y (locate on site plan) Materials of construction: ,[G9 Dimensions: • .4)4 Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): _/7n i�7ii i ti nn} nno�on J 9 l Page 10 of 11 '"' •:h OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 480 'lain St�ceet Ozteltvtzte, Owner:Ve%.non Boud zeau Date of Inspection: 8/1/0 3 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all welts within 100 feet. Locate where public water supply enters the building. Q I \ I 'ermission is here lystem located at � I i nd as described in h1� bmply with Title S Irovided:Construi Sate: 171 10 Page 1 l of I 1 ''"� ';► OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:4 8 0 Main S.t ne e t< e2v, e, Owner: Veznon Date of Inspection: 811103 F SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: yam_Obtained from system design plans on record-If checked,date of design plan.reviewed: 811103 L/f.L_Observed site(abutting property/observation hole within 150 feet of SAS) yam-Checked with local Board of Health-explain: P-icked al? a.a P u.i.2t - ''LS_Checked with local excavators, installers-(attach documentation) qF,� Accessed USGS database-explain: .t t p:i-own, aazn.6 a' gie, ma. u s. You must describe how you established the high ground water elevation: 11,6ed: gahle;tq R Mi.t.Pe�z Mode-P. 12116194 G2ound wa.telt eievat.ionz agove .sea Pevee, 116ed: 11iCS! ('PAPa»n}lnn wp_Le data, dune 1992 11,6ed: 1ls4s! Zechnirn0 PiLLPpiin 92-000- 1 10-Rate #2 �aaua.,zy 1992 Annua.0 zange.6 n� na.n�in_rL nnfon ohpvnf�nn.t_ 3-500 gaiion 1I 2each.ing chamge2s. iz ` 4 6" ,eet Groundwater: feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is b feet. I j 11 ` '.•�rT�n'1'��.Tr'1n►�JT•I.i.•ITT.f.TtlR1.1T�1Af�11.1�RIT1f.RR1tAl7I�.f 19 �I TOWN OF Baanztagie [lOARU OF HEALTH ,SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP�ECI'ION FORM - PART D .- CERTIFICATION I -TYPO OR PRINT CLEARLY- PROPERTY INSPECTED - STREET ADDRESS 480 Main Staeet Obteav•i•e•Qe, Ma.3.6. ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Veanon Boudaeau PARV D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J P Macomber & Sou Inc" COMPANY ADDRESS Box 66 Centerville Mass. 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 578 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 . • n i Ili� l Check one : :_Z/� System: PASSED L ' 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 16 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con cted has found that the system fails to Protect the i-itiblic health and the environment in accordance with Title 6', 310 CMR 16 . 303, and as specifically noted on PART C - FAILURE CRITERIA- of this inspection form, 4/" Inspector Signature A Date 0 J �� ' ne copy of this c ication must be provided to the OWNER, the BUYER ( Where applicable ) and the BOARD OF HEAL11!I. +' If the inspection FAILED, th-e owner or•""operator shall upgrade he aYstem- within one year of the date of the inspection, unless allowed ortrequired . ' otherwise as provided in 3,10 CMR 16 . 306 . partd .doc TOWN OF BARNSTABLE i I i LOCATION S[O M 01.t1-) SR' SEWAGE # 9 VILLAGE V-i-,JEA i ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. O AAn M 6S�te, 'I7 ° 3 T" SEPTIC TANK CAPACITY 1 � LEACHING FACELITY: (type) 3 (size) !3d NO. OF BEDROOMS ' E .f=PEWOR OWNER A09 !14411140 P94!a_ PERMUDATE: 4" —/J!--ft COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) l , Feet Furnished by r" f N. ' / Fee$ 5 0. 00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipplicatton for �Digoe; Y *p$tem Cow5truction Permit Application for a Permit to Construct( )Repair( )Upgrade O(X)Abandon( ) EJ Complete System El Individual Components Location Address or Lot No. 480 Main Street Owner's Name,Address and Tel.No. Osterville ,Mass. Shepherd Vanvoorhis Assessor'sMap/Parcel A// ® / 480 Main Street Osterville ,Mass . Installer's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 02655 J.P.Macomber & Son Inc . J.P.Macomber & Son Inc . Box 66 Centerville ,Mass . 02632 Box 66 'Centerville ,Mass . 02632 Type of Building: Dwelling X No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 462 gallons per day. Calculated daily flow 4 x 110=4 4 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1500 + Box Type of S.A.S3-500 gallon chambers Description of Soil Loamy sand to medium fine sand . Nature of Repairs or Alterations(Answer when applicable) Omitting cesspools, Installing 1-1500 tank.Distribution box and 3-500 gallon chambers packed in 4 ' of stone. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board f ealt Signed Date 4/16/9 9 Application Approved by Date - Application Disapproved for the following reasons 42 Permit No. ` Date Issued �' E Fee$ 50.00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS r 01pprfcation for )Digpoga[ *pztem (tonaruction Pen itit Application for a Permit to Construct( )Repair( )Upgrade X X)Abandon( ) ❑Complete System ❑Individual Components Loca_ion Address or Lot No. 4 8 0 M a i n S t r e e t Owner's Name,Address and Tel.No. Osterville,Mass. Shepherd Vanvoorhis Asse'.sor's Map/Parcel O / 480 Main Street Osterville ,Mwss . , _p Instal_er's Name,Address,and Tel.No. 5 0 8—7 7 5—3 3 3 8 Designer's Name,Address and Tel.No. 0 2 6 5 5 `• J.P.Macomber & Son Inc. J.P.Macomber & Son Inc. I It, Box 66 Centerville,Mass. 02632 Box 66 Centerville ,Msss. 02632 Type of Building: Dwelling X No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 4 6 2 gallons per day. Calculated daily now 4 x 110=4 4 0 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1600 + Box Type of S.A.0-500 gallon chambers Description of Soil Loamy sand to medium fine sand . Nature of,Repairs or Alterations(Answer when applicable) Omitting cesspools. Installing 1-1506 tank.Distribution box and 3-500 gallon chambers packed in of stone. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the,Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Boar of Veal ealt Signed , Date 4/16/9 9 Application Approved by Date Application Disapproved for the following reasons Permit No. 77, ` Date Issued . THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS rtificate of (Compliance ,' THIS IS TO CERTIFY, that the 6n-site Sewage Disposal System Constructed( )Repaired( )Upgraded X X ) Abandoned( )by J.P.Mac6mber & Son Inc. at 480 Main Street 0 s t e r y i l l a ,Mass. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N . dated-,4-'--f!C' ' Installer J.P.Macomber & Son Inc . Designer J.P.Macombe " & Son-Inc. The issuance of this permit shall not a qqstrued as a guarantee that the sy will function s designed. Date__ I�'"' Inspecto E -- --------------------------- -- No. Fee$ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS ligooal 6potem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(X X)Abandon( ) Systemlocatedat 480 Main Street Osterville,Mass. 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. I Provided:Construction must be completed within three years of the date of th'. rmit. Date: Approved yl� f ' r 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, Joseph P.Macomber J r . , hereby certify that the application for disposal works construction permit signed by me dated 4/16/9 9 concerning the property located at 480 Main Street Oaterville ,Mass . meets all of the following criteria: The failed system is connected to a residential dwelling only' There are no commercial or business uses associated with the dwelling. M The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. /There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed (1" There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor m od when applicable] If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 3 B) G.W. Elevation Cr +the MAX. High G.W. Adjustment. 7 _ /19 DIFFERENCE BETWEEN A and B °� 3 I D • J � c S GNE DATE: [Sket " oposed plan of system on back]. q:health folder.cen f © O0 vie "-ea, LOCATION SEWAGE PERMIT NO• .VILLAGE I N S T A LLER'S NAME A ADDRESS ~snn e s pe ` c •�1�4 W,UILDE R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE I-SSUED Y �J6 yjoc.D e �'v�ry s sT