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HomeMy WebLinkAbout0886 MAIN STREET (OST.) - Health 886 MAIN S'I X E -- - A-117�062 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 886 Main St Property Address h Owner Amy L Gardner Living Trust ; information is Owner's Na" a required for Cotuit ✓ Ma 11-26-19a every page. City/Town State Zip Code Date of Inspection - •�q Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. Inspector Information Sly /�3D When filling out forms on the computer, use Douglas A Brown only the tab key Name of Inspector to move your D.A.Brown Inc cursor-do not Company Name use the return key. P.o Box 145 Company Address Centerville Ma 02632 City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 11-26-19 Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ` Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 r , " Commonwealth of Massachusetts �m 1P Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main St _ �� Property Address Owner Amy L Gardner Living Trust information is Owner's Name required for Cotuit Ma 11-26-19 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: At time of inspection this system met or exceeded all passing requirements. This report can not predict the future performance under the same or increased usage. This report is not to be used for definitave bedroom count determination as we are going what info is available to us at time of inspection. This system was installed in April of 2001 (17+ yrs old) 2) System Conditionally Passes: I ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 lip" Commonwealth of Massachusetts Title 5 Official Inspection. Form I° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 886 Main St Property Address Amy L Gardner Living Trust Owner information is Owner's Name • required for Cotuit Ma 11-26-19 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main St Property Address Amy L Gardner Living Trust information is Owner Owner's Name nfor required for Cotuit Ma 11-26-19 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 - _J r Commonwealth of Massachusetts �n l? Title 5 Official Inspection Form Subsurface Sewage Disposal SystemForm Not for Voluntary Assessments 886 Main St V/ Property Address Owner Amy L Gardner Living Trust information is Owner's Name required for Cotuit Ma 11-26-19 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 886 Main St Property Address Owner Amy L Gardner Living Trust information is Owner's Name required for Cotuit Ma 11-26-19 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I c Commonwealth of Massachusetts 113 Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form Not for Voluntary Assessments 6 � 886 Main St V Property Address Amy L Gardner Living Trust Owner information is Owner's Name required for Cotuit Ma 11-26-19 every page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: According to as-built card this system consists of a 1500 gallon septic tank, d-box, and 3 500 gallon chambers as shown Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection . ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if.available (last 2 years usage (gpd)): Detail: This system is NOT designed for use with a disposal. Water usage was not available the time I typed report. Sump pump? ❑ Yes ❑ No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �m i.? Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main St Property Address Owner Amy L Gardner Living Trust information is Owner's Name required for Cotuit Ma 11-26-19 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: r Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume,pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4� 886 Main St Property Address Amy L Gardner Living Trust inform Owneration is Owner's Name required for Cotuit Ma 11-26-19 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: as-built states system completed in April of 2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form u Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main St Property Address Owner Amy L Gardner Living Trust information is Owner's Name required for Cotuit Ma 11-26-19 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 per as-built Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I always recommend pumping at time of transfer if tank has not been recently pumped and at least every 2-3 yrs there after for maintenance depending on usage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form /Y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main St Property Address Amy L Gardner Living Trust Owner information is Owner's Name required for Cotuit Ma 11-26-19 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form v Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I V 886 Main St Property Address Amy L Gardner Living Trust Owner information is Owner's Name required for Cotuit Ma 11-26-19 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Box was functioning properly at time of inspection. Box looked typical for its age with some corrosion there were no signs of solid carry over. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �m liip Title 5 Official Inspection Form II' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main St L Property Address Amy L Gardner Living Trust inform Owneration is Owner's Name required for Cotuit Ma 11-26-19 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Due to depth and possible under ground utilities in the area. Type: ❑ Teaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number:' ❑ innovative/alternative system t Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main St Property Address Owner Amy L Gardner Living Trust information is Owner's Name required for Cotuit Ma 11-26-19 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There were no signs of failure in area of s.a.s and also no signs of failure based on viewing the d-box. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum'layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L� 886 Main St Property Address Amy L Gardner Living Trust inform Owneration is Owner's Name required for Cotuit Ma 11-26-19 every page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main St Property Address Owner Amy L Gardner Living Trust information is Owner's Name required for Cotuit Ma 11-26-19 every 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts ` ry w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main St Property Address Amy L Gardner Living Trust inform Owneration is Owner's Name required for Cotuit Ma 11-26-19 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water:, 5+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 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: design plan and attached as-built rBefore 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 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 886 Main St Property Address Owner Amy L Gardner Living Trust information is Owner's Name required for Cotuit Ma 11-26-19 every page. Cityrrown 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 as completed appropriate p 4 (Failure Criteria) and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank— Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 r -Assessing As-Built Cards Page 1 of 2 / ,A TOWN OF BARNSTABLE LOCA ON � /�L,e?h7 3 SEWAGE q z�12©a �H LAGE ASSESSOR'S MAP&LOTD3-5—eg'/ INSTALLER'S NAME&PHONE NO.�'or raL�Y�I �/1,.g1( 77/-9399 SEPTIC TANK CAPACITY /SOP Z,t 6 LEACHING FACILITY:(type)&Q eil ta s «l,(3 1 (sue) ,e va jt? NO.OF BEDROOMS BUILDER ORIOOOWNER PERMITDATE: �f-k'al COMPLIANCE DATE: 'Y-z7-0/ Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility f f 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) J Feet Furnished by i i v7 c/ 00 V https://townof bamstable.us/Departments/Assessing/Property—Values/HMdisplay.asp?map... 11/26/2019 'Assessing As-Built Cards Page 2 of 2; https://townofbamstable.us/Departments/Assessing/Property_V alues/HMdisplay.asp?map... 11/26/2019 No. Q=a 3 ' Fee ®V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYication for �hgpozat �§p!tem Cori.5truction Permit Application for a Permit to Construct( ) Repair(grade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. J�/ Owner�Nam Address,and Tel.No. Assessor'sMap/Parcel 1,70 X—A 1QP_ 4a „ /g-: Installer's ame,Address,and Tel.No. v' G' ' � Designer's Name,Address and Tel.No. � aJr ,eke 7J-w C,�&tia� , Type o uilding: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building a��o S�¢.5� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank 1000 641 Type of S.A.S. Caaj Description of Soil Nature of Repairs or Iterations(Answer when applicable) L i e, 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 Environmental Code and not to place the system in operation until a Certificate of Compliance has been issZ�d =d�flth. S' Date SJ�t /e/.1 Application Approved by Date Application Disapproved by: Date,. for-the-following reasons Permit No. CDate Issued No. . .00 ( a 3�" _ �o _ � � Fee� - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes ..PUBLIC HEALTH DIVISION - TOWN'OF BARNSTABLE, MASSACHUSETTS _ Rpplication for Mizpodal �&pgtem Cow5truction Vermtt P /• Application for a Permit to Construct( ~) Repair(Xupgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. / Owner's Name,Address,and Tel.No. lass PEAA - �!/!�AS�6^�^�Assessor's Map/Parcel 1170 �S Tyy�'��v s '(�° / SCE ar ' ®� �7/ 1 Installer's Name,Address,and Tel.No.` /\J� -eeOSS Designer'Name,Address and Tel.No. �7l.Jarl L. --Shan__)- Type&' uilding: ' Dwelling No.of Bedrooms Lot Size s sq. ft. Garbage Grinder ( ) Other Type of Building ,&UP'Slld S:. No of Persons' Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets l Revision Date Title Size of Septic Tank e!:; l Type of S.A.S. &W Description of Soil Nature of Repairs or Alterations(Answer when applicable) Line. (PDlGelP 8 ro .', ! {�7,7 _/_o J r / " Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by thisiBoard1off//H.e�alth. S' ned (/`u///�/ Date �_Zl�I/ Application Approved by Date Aj , y Application Disapproved by: Date 1 for the following reasons Permit No. Date Issued ,P THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Urtiftrate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (, 1 ) ,Upgraded ( ) Abandoned( )by 1. 1 at 4/.., e has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. b 4")-.3 dated Installer 0', /6,i A"(-- Designer #bedrooms `-i Approved design flow gpd The issuance of this permit shall of be construed as a guarantee that the system ill functio e igned. Date �1 Inspector ---------------------------------------------- No. C)c5(0 Fee c THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS wigool �&pgtem Con5tructton Permit Permission is hereby granted to Construct �)�Repair ( ) Upgrade ( ) Abandon ( ) System located at I A I vV I I I and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special connddition . Provided: Constructio must be o pleted within three years of the -date of this pelt .it. Date (V Approvd by _ i TOWN OF BARNSTABLE I LOCATION 886 Main Street `'"""` SEWAGE # �' .I:AGE Osterville ASSESSOR'S MAP & LOT AM�41&&PHONENO. J_P.Macomber & SonInc 775-3338 SEPTIC TANK CAPACITY 1 000 gallons LEACHING FACILITY: (type) leaching pit (Size) 1 000 gallons NO.OF BEDROOMS J e=_ R�OWNER John Alger PERMITDATE: COMPLIANCE DATE: `.A Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet -.Furnished by rylain t i /00 .Aj O DATE:_ 1 0/2L00 --- PROPERTY ADDRESS:-- ------ 886 Main Street______ _0stervillg,�_1` On the above date, I Inspected the septic .system at the above address. This system conslsts of the following; 1 . 1 -1000 gallon septic tank 2. 1 -1000 gallon leaching pit 3. 1 -Distribution box Based on my Inspectlon, 1 certify the following conditions: 4 . This is a title five septic system. ( 78 Code) '. The septic system is in proper working order at the .present time. SIGNATURE:„/ __ _A Na me 1,3. ------ 0 6 Company Jo3!Qh_P _ Hacomber_& Son , Inc . Address:_ Box-66—_ __Centerville a _02b32-0066 Phone:___ 508_77S_ i THIS CERTIFICATION OOES NOT CONSTITUTE' A OVARANTY OR WARRANTY J6SEPH P. MACOMBER & SON, INC, T�nks•Cesspoois•Lesehllelds . s� k Pumped i. Instilled Town Sewer Conneotlons P,o, Box 66 CsntsrYllle, MA 026J2.0066 ` 00, 775•3338 775.6412 00� oFe°�o�• ' E COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.6600 TRUDY COKE 3ecreuuy DAVM B. STRUHS AROEO PAUL CELLUCCI Commissioner Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECT}ON FORM PART A CERnFiCAT10N Addr"s: 886 Main Street Nartsa of owrw John 1 r PTOQ"ty Address of owPw: Box Osterville ° bat,of kupecdon: 0 Osterville, Ma. 02655 Ltd„: (�.&SIo Joseph P. Macomber Jr. 1 am a DEP approed v system 4upactor pursuant to ion Sect 16.340 of Thfa 6(310 CMR 16.000) c ,,,yK,f7e; J0S h P. Macomber & Son Inc. oxCenterville , M 632-0066 T""phone Pkmsbar• — — C£ftTUiCAT10N STATEMENT e di inspected the sewagsposal system at this address and that the Information reported below Is true, accurate I certify that I have personally In paced The Inspection was performed based on my training and experience In the proper function and and complete +s of the time of mantlnance of on•sks swage disposed systems. The system: /—VIP+sads _ ConditJonally Passes _ Needs Further'Evaluation By the Local Approving Authority Fails I / I Data: Vupector's Sigrwwre: The System Inspector shall submit a copy of this Inspection report to the Approving Authority (Board of Heafth or DEP)whhin thirty (30) days of completing this Inspection. if the system Is a shared system or has a design flow of 10,000 gpd or greater, the Inspector and the system owner shelf submit the report to the appropriate regional office of the Department of�C-tvironmertM fsTotectlon. The original should be sent to Vw system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page 1 or 11 �' Printed on Recycled Piper SVi3URPA09 SEWA09 D13POM SYSTEM 1N3KCT10N FOPJA PART A > CFRT1FICAMN (00ndra4047 Pyoq.rryada..#; 886 Main Street-,Osterville John Alger D.cs of `"`°"`sw: 1 0/2/0 0 Ft3PECn0N SUTAM .AY:... Ch ck A. B, C, or D: A. SYSTEM PASSES: I have not found MY WO(rnsdon wNCh In CC$$ that any of the falluto cortd)dorta do&cribod In 310 CMA 14.303 444L any f criisria not ovaJustod ws IndJcaled below, Ca IIJa.ENT3; B. SYSTt7d CONDR10NAUY PASSES: —AILone or more system oomponnt os as do#orlbod In the 'Co"do" ►"s' sootlon Mod to be roplaood or rspelrod, The s".tsm. �a com%oodon of the repiscomont a rspalr, as approved by the Sowd of HoWth, will pass, fnd7csts yes. no, or not detorrNnod (Y, N. w NO). Do#cribe basis of downilnadon H #8 lnstarsaes, If 'not detorrrJ^*d', oxj)-laln why not. The sspdc tank is metal, U4464 the Owner a operotw has prov(ded the oyotom Uupootor wtth a oopy of a C+rVAcate of CompUsnce (snsched)IndJcedn9 that the tank was Inat"od wlthIA twenty (20) Yowe prior to the date of Uw wpvcoon the sspdc tank, whethsr or not motel, Is orooked, oVvowratly unsound, chow#sub#WtIAJ 1ANVOCIOn a erfVvsdon. o+ I.11ure Is InuNnont, The system will pass IrupsoUon If the OxJ#Un9 #spdo tank 1# repUcsd whh o comp1ytn9 sspdc L" approved by the Board of Health. Sews90 bockup or brookout or N9h stado water Isvol observed in the c9stribudon box la due to broken of obrtn,ccsd pip or due to a broken, settled or uneven dJ#VlbuUon box. The #ystem wUJ pea#InapooUon If (wt'Z approveJ of trw Bawc of HeaJth). Woken Alpo(#) we roplaced obswcdon 1# rornovod dJsvlbudon box 1#loyoUed w roplacod �_✓()• The sMsm fsquired pumpblgm m%him-fourdmos-a"ardue%o broKenw obovvoted plpe(O. The tYvtrm ww-Pwvv^ Inspection II(with approved of the bard of Hoslth): Woken pJpo(s) are roploced obstruction Is removed , revised 9/2/98 P.c`3eril i SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM � PART A CER'nFiCAnciN (co"dro od) Pogerry Address: 886 Main Street, Osterville 0-wrw: John Alger °'ce 7f 10Aap.ac60n. 1 0/2/0 0 C. FURTHER EVALUATION IS REOUIRED BY THE BOARD OF HEALTH: Cond1dons exist which require further eva)usdon by the Board of Health In order to determine If the system is WUng to protect tf- public health. safety and the environment. 1) SY3TEM Will PASS UNLESS BOARD OF HEALTH DETFRJNINES W ACCORDANCE WITH 310 CZAR 16.303 (1)(b)THAT THE SYSTEM 1.3 NOT RJNC71ONW0 W A MANNER WH)CH.WILL.PR03TCT THE PUSUC HEALTMAND SAFETY LkO THE BCaB0kAEWL Cesspool or privy Is within 60 feet of surface water Cesspool or privy Is within 60 lest of is bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUSUC WATER SUPPLIER, IF ANY)DETPRUD ES THAT TH.E SYSTE3d IS FUNCTIONINO IN A frtANNER THAT PROTECTS THE PUBUC HEALTH AND SAFETY AND THE EINMON LEMT: The system has a septic tank and soil absorption system (SAS) and the SAS Is within 100 feet of a surface water wppiy or tributary to a surface water supply. The system has a *optic tank and soil absorption system and the SAS Is within a Zone I of a public water supply well. The system hes a septic tank and aoll absorption system and the SAS Is within 60 feet of a private water supply wau. The system hes a septic tank and soil absorption system and the SAS Is lose than 100 feet but 60 foot or more rrom a private water supply well. unless a well wotor analysis for collfo(m bacteria and volatile organic compounds Indcatas 0%&1 L"' wall Is free from pollution from that facility and the presence of ammonia nJvogen end rtiusto nJVwo'n Is equal to or less than 5 ppm. .Method vied to determine distance tiW lapproxlmrdon not veld).- 3J OTHER ti revised 9/2/98 Pigt3or)l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERT11FICKnON (cortdnU4d) propeMAd&*": 886 Main Street, Osterville Owner: John Alger Date of tnapecton 1 0/2/0 0 D. SYSTEM FAILS: You must Indicate either 'Yes' or 'No' to each of the following: I have determined that fl;d ebor me of lowor ThetBo4rdloWH althhe foloing ishouldure nbe dcontacted to determin•ons exist as describedIwhat willlbe necessary to corTW the f'" determination Is identl Yes Nov nertt doeto am ovefoicrvWggwd�S.Or'cNtp**I• Backup 04"Wage ino40clNy-o•eT01 conpo .j.••.:••�— Discharge or ponding of effluent to the surface of the ground or surface'weters due to an overloaded or dogged SAS or •— � cesspool. Static liquid level In'tht dl�trriby{d ¢Py� on'bQx'a �utlet.lnw d rt due to an overloaded or clogged SAS or cesspo • 4cY11�vf Liquid depth Iris�a+Po�l+ less than fS' below Invrart or available volume is less than 1/2 day row. f/ Required pumping more than 4 times In the last Year NOTdue to clogged or obstructed PIDe(i1• _ Number of limas Pumped 0 • Any portion o1 the Soil Absorption System, cesspool or privy Is below the high groundwater elevation. Any portion of a cesspool or privy Is within 100 fast of a surface water supply or trlbutary to a surface wet*( wPWY Any portion of a cesspool or privy Is-wlthln a Zone I of a public well. Any Portion of a cesspool or privy Is within 60 fast of a private water supply well. -than 100 feet but greater then 60 feet from a private water wPPI Any portion o1 a cesspool or privy Is less Y v+eu wits, n acceptable c at erl qualitilaanalysis. It the well hammonla Ntr 9en`andenluate Ntlogen.sch copy of well water analYe s to wae-colliorm ba E LARGE SYSTETA FAILS: 'Yes' or 'No' to each of the following: You must Indicate either The following crltaris apply to large systems In addition to the criteria above: rJAcant tfveat to ,uV The system serves a facility with a design flow of 10,000 gPd or greater(large System( ►n0 the system Is • Ng s one or more of the following conditions exist: health end safety and the environment bocoua Yes NO/ the system is within 400 feet of a surface drinking water supply er to wrl�w�s4 Massy"w►fIY r the system irwltkH+ 200 Ire(of•1-M�►t Y Zor+e n of a P. system Is located In a nitrogen sensitive area (interim Wellhead Protection Area •IWPA) or a rT++DD�d Wolof supply Welly The owner or operator of any such system shall upgrade the system In accordance with 710 CMR 16,704(21. Pts+se consort t>,s foul rK oMce of the Department for further Infognstion. Pais a of If revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTDA INSPECTION FORM PART t ' CHECKUST Property Ad&a": 886 Main Street, Osterville own«: John Alger Deu of bupectton: 1 0/2/.0 0 Check 11 the following have been done. You.must IndIcste either 'Yes' or 'No' as to each of the following: Yet No Pumping Informadon was provided by the owner, occupant, or Board of Health, None of the system<wroo—rtta 6&6WA n pwnpa 4tJaa3t two•ws"4&A44.1 elYsum haabawwcslz og ea.e.sal false during that period. Large volume* of water have not been Introduced Into the *y*tom recently or ae pan of ups Inspectlon. At built plane have been obtained and exemined. Note If they are not available with N/A. _ The facility or dwelling was Inspected for signs of iewage backup, -t—V The system does not receive non•eartJtary or IndustrW waste flow, _ The eke was Inspected for signs of breakout. _ All system component;•:*�,cIu ding.th*,3oll,Absorptlon System, have been located on the efts. _ The septic tank manholes were uncovered, opened, and the Interior of the septic tank was Inapected for condition of oe or tees, material of constructJon, dlmenslona, depth of Uquid, depth of sludge, depth of scum. / The size and locadon of the Soil Absorption System orrthe sit@ has been determined based on: Y Exlsdng Information. For example, Plan at B.O.N. _ Determined In the field (11 any of the failure criteria related to Part C Is at Issue, approxlmatJon of dletance Is unaccepu. (I5.J02(J)ib)) The faculty owtw t".—c-p-nt Jf diHw&w from.ownarl.wrara. 4ouldid wlih Win—flomon WAp•o.p— T-;n,•�� SubSurface DlsposaJ Systems. revised 9/2/96 ratesofI I SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORMA PART C SYSTEM WFORIAATION Proq+rty Addres-a: 886 Main Street, Oster.ville, owrw: John Alger Date of Inspection: 1 0/2/0 0 Ftrow CONDITIONS R ES IOFNTIA is . peslpn Flow: _g•p•d./bedroom. Number of bedrooms (deslpn):.� Number of bedrooms (actual): Total OESION Flow_ Number of current rosldsnts: Osrbage grinder(yes or no): _ Loundry (separate system) (Yes or no)&: If yes, soparaLslnspacdon,nqulred Laundry system Inspected (yes of n0) Seasonal use (yes or no):- usage (ppol: �r Water motor readings,It available (last two year's f Sump Pump lyes or not: e� �i'� Last date of occupancy: ijA CO MMERCLA I D TR Type of esubllshmenC e Design now: �(�Basqd on 16.203)Basle of design flow oreass trap present: (yes or n industrial Waste Holding Tank prsssnt: (yes or no)-Iiy, Non•saritary waste discharged to the Tide 6 system: (Yes or no).9 Water motor readings, It available: List date of occupancy:'a-';y'e OTHER: (Describe) last Oita of occupancy: — • GENERAL INFORMATION PUMPING RECORDS rd s S q formation: e System pumped as part of inspection: (yes or no)_ II yes, volume pumped: —gallons Reason lot pumping: Ili TYPE AF Septic t Septic cankldistributfon box/soil absorption system A)c)_ Single cesspool A,r— Overflow cesspool NO Privy Shared system(yes or no) (if yes, sttsch previous Inspection records, If any) IIA Technology etc. Attach copy of up to date operstlon and maintenance contract Tight Tank _Copy of DEP Approval Other A � Apt,ROXjjAATE AGE of all components, date inetagodiif known)-end sous94 04404wmadon: Sewage odors detected when•srrlving at the site: (yes or no) revised 9/2/98 page 6of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECf10N FORM PART C SYSTEM INFORMATION (con*%u*d) ProgertyAddrw: . 886 Main Street, Osterville Dwrw; John Alger Dieu of w4pocdon: 10/2/00 BUILDING SEWER: (Locate on site plan) d Depth below grade:( Materiel of con►vvctlon:,a cast Iron /40 PVCA,�other (explaln) Distance from private water supply wall or suction line Diameter a .. Comments: (condition of)oints, ventlng, evidence of hak"e,-etc.) Joints a o e Nviden em ven e r SEPTIC TANK: (locate on slit plan)Depth below grade' e /� ,i� Materiel of construction: ygoncrettAO metalFlberglasHlLPolyethyten other explain) xj If lank Is fneta). list age tf )s.&Qo.confVmed by Cert)ncats of Compllencs (Yes/No) D,mensions: 6 y Sludge depth: Distance from top sludge to bottom of outlet too orMMrr Scum tNcknass: -sir ' Distance from top of scum to top of outlet tot or belle: Distance from bottom of scum to botto ' of outl01 t or b►Me: Mow dimensions were determined: zaad— Comments: ondition of Inlet end outlet•tees or•bstfles, depth of•Ilquid level In relation to outlet invert, atructvrar`wnlagrrty, uecommendation for pumping, c evidence of Isakagt, etc.) 'PUm seis fifty tees are - liquid- 1 no evidence one e tan o ea a GREASE TRAP: ' (locals on site plan) Depth below grsds: Materiel of constructionAAconcretokamet&LoCLLFlberglass+d/PPolyethylena4:Aotherlexplainl Dimensions: Scum tNckness� . Distance from top of scum to top of outlet tee or belle:- . Distance hom bottom of/s�cum to bottom of outlet tot or bafftrt � Oats of lest pumping: A21— Comments: Irecommendadon for pumping, condition of Inlet rand outlet tees or baffles, depth of Uquld level In relation to outlet Invert, structural Integrity. evidence of leakage, etc.) rease r revised 9/2/98 ` Pa`e7orlt SUSSURFAU SEWAGE DISHOSAI SYSTEM WSr£CTION FOP-M PART C SYSTEM W FO R"T)O N (corrtLx►.Q1 r'roq.rtY Adbs►a: 886 Main Street, Osterville John Alger 10/2/00 nOKr OA HOIDLHO TANK:�:IT►nk mvet be pumped prior to, or •t Ume of, Inapecdon) (locate on We plan) Oepth below gradf:AA Material of con►wctlon: concrete�mataJ/ Flb�rplaa�((�'oly�thylanv�otharl�xpl►ln) t Olmension►: AN CapaclTY: 9411ons Design flow: g►lions/day Alarm pre1enl Alarm level: Alarm I yvorking order YoVL,�NOV Gate of p(eviovr pvmpino: M9 Corrvnanu: Icondoon of Inlet lee, condlUon of alarm and floe% switches, Co.) } E� E:S CK5 R18LMON SOX:/ notate on Nte plaril Osptn of tigvld level above ovdet Invert: AM Commenu: evidence of leakage Into or out •1 ttro:, OW) If level end disirlbvUon Is equal, evidenw of solids carryover, is evidence oT7Tqlids carry _ lea r out of the box. PUk,IP CMA1dBER:4Z1A,'e— Rotate on the plan) Pump► In working order: (Yes or NO) Nl�l A161mt In wo(kln9 or" (Yes or No),= Commenu: ► rtonances, etc.) mote conGUon of pump chamber, condlUon of pum s p end Dp� 5—chambeses Pelf Iof11 revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C l SYSTEM INFORMATION (continued) Propem Address: 886 Main Street, Osterville OWTW` John Alger D.0 at Inao•.ction: 1 0/?,/0 0 SOIL ABSORPTION SYSTEM(SAS): Ilocats on site plan. If possible: excavation not required, location may be approximated by non-Intrusive. methods) If not located, explain: Type. leeching plis, number. Isaching chambers, number: 0 leeching galleries, number. Isaching wenches, number, length: Q Iesching Acids, number, dlmenslon overflow cesspool, number, Alternative system: #t p Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of pondlny, damp soli, condition of vegetation, etc.) Loamy ;anti t(-) marl; ,,m fire: sand. o signs of hydraulic failure or p , ng- Sui 1 G era r1rT Ve tatic�ri is ii^v llle3� CESSPOOLS: . (locate on site plan) Number and configuration: D Ospth•top of liquid to Inlet Invert: Depth of sollds layer: Depth of scum layer: Dimensions of cesspool: Materiels of construction: Indication of groundwater: Inflow icesspool must be pumped as part of Inspection) Cesspo0 G ar not present- Commenu: mots condition of soil, signs of hydraulic failure, level of ponding,condition of,vegetation, etc,) C'aaG=n,nrnl c are nGt ^r'6BeRt PRM: llocate on site plan) Materials of construction: Dlmenslona: A-# Oepth of solider Commenu: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.) revised 9/2/98 Psee9of11 • SV93VAPA"frWA09 013POSAL iy9TW LNXPt 10N FOIW FART c s y s TW W FO RJdAT10 N (aonttrr�dl Prop«cyAddeo"; 886 Main Street,. Osterville °~""" John Alger Dou p+vupov +: 1 0/2/00 SKETCH Of SEWAQE OtSnSAL SYSTEM: Inc:udf djr to it Is&it two perm&nsnt relorsncs landmuks 0(benchmuki 1o6&t1 .:I will, wltNn 100' (l.ocits wh4rs publlo wjtsr wpply aomss Into house) y� q O QO O revised 9/2/98 h{t 10 0(11 ' R SU93URFACIE SEWAGE Dl3/QSAL 3Y3TDA WS/ECTION FORM ' PART C , SY3TE?A y�FOAWAMN (aorrdn+�dl ftopwyA6&"a; 886 Main Street, IOsterville Owrw: John Alger Da, of t%9--6on: 1,0/2/00 MRCS Rrrport name Soll Typo_ Typlc►J depth to groundw+tor VSOS Oil# wob►Ite Allied Oworv►tlon Wells checked Mod�nt• D��p Drovndw►tor depth: Shallow SITE EXAM Slope Svrf►ce water Check Cello# Sh&Jlow well► Ertrnat.d Depth to OroundwItt•(;4fi-jFggl ►►r► Indlc►tq NI the methods vied to dotorminq High Groundwater Elevation: Oo%&Jn9d from Design Plans on record �0 r.rv�d Slt� IADutdng prop�"Y obiorvodon holm, befom9ol wmp ote,) o,urmin►d from local condition► Chocked with local Board of health Checked FEMA Maps �h►Old pumping records Yheckld local a►c+v►tor►, In►tolle(l Vied USOS Date D11criD► how You established thi High Oroundwelor ElwotJon. lMUIJ be completed) Used; Water Contours Map Gahrety & Miller Model 12/16/94 _ hf;ellorll revised 9/2/98 ..n.. n .�.-r.-..w-w•r..+r--rw.'wwrww n+.+w•w.��w•..nT*u'wnr.�n re. '�r"'^'r 'I'UNN OF BARNSTABLE WARD OF HEALTH � 9U119URFACF 9FWA(;F. 1)1 3f'09AL SYSTEM I 83I FCTION FORM -' PART D - CERTIFICATION -TYPO OA FAINT CI.CAALY- PROPERTY IKSPECTED STREET ADDRESS 886 Main Street,, Osterville ASSESSORS HAP , DLOCK AND PARCEL $ OWNER ' s NAHE John Ald _r PART D - .CERTIFICATION NAHE OF INSPECTOR Joseph P . Macomber Jr, COHPANY NAHE Joseph P . Macomber &- sbn, Inc . COHPANY ADDRESS 13ox 66 _ Centerville MA. 02632-0066 Strtvt TOvn or c --ty i IIP COHPANY TELEPHONC ( 508 ) 775 - 3338 FAX (508 J 790- 1578 CCRTIFICATION STATEMENT I certify that I have personally inspected the sewage dieposa`1 system nt this nddress and that the information reported is true , accurate , and omplete as of the time of . inspection , The inspection Has 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 Check one ; 4 System PASSED The. Inspection vhich I have conducted has not found any information which indicates that the system fails to adequately protect public IjenlLh or the environment as defined in 310 CHR 16 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form, System FAILED* T; e inspection which I have con tcted. has found that the system fails to protect the E)tiblic health and the environment in accordance with Title 5 , 310 CHR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this Inspection form . Inspector Signature r Date " '� a Dne copy of this ert,ification must be provided to the OWNER , the BUYER wh. r. •Nplloable ) and the BOARD OY HEAL'1'll . "�.w • I ! the inspection FAILED , thb owner or operator shall upgrade ' the eyetem within one year of the dote of the inspection , unless allowed or required otherwise as provided in 3.10 CHR 16 . 306 partd . doc I L O CATION S E W A GE PERMIT NO. VILLAGE f I N S T A LLER'S NAME i ADDRESS e U I L D E R 0R OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED _.- �� �"' ------------ r. �Q. p o w No ..........1_.... —-- Fss S R....0........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH D.S-t> ..................OF......6�Oe.h....S../.kkle....................................... Allpfiraften for Uhipati of Varks Tomitrurthin Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: g. _.. ..................................................................... � �: ...........5 r...........a�...._..-...... �^ Location-Address or Lot No. .............................................. ......'` --•--•-----------•-••-•-.....-----------.......... Owner = Address a , # ✓....._., ,ru1�: ... ........ ....... _. __tP!r v,..... :. .----.....------------........................--- Installer Address {� -t UType of Building .-Size Lot............................Sq. feet Dwelling—No. of Bedrooms_______ _________________________________Expansion Attic ( ) ` Garbage Grinder ( ) per, Other—Type of Building _4�. �I_::-. No. of persons___.__. ( ) Cafeteria ( )............. Showers — a' Other fixtures --------------------------------- W Design Flow.......................................... gallons per person per day. Total daily flow.............._.............................gallons. WSeptic Tank—Liquid capacity-__--_-____gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation.Test Results Performed by.. Date,-,,..................................... Test Pit No. 1................minutes per inch Depth of Test Pit-------............. Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q+' --••--••-•-•----------••----••••--------•-•---••••--•----•...............••............•--• ...-•----••.•---- ----•••--•----•-••.._.._..----..---•- 0 Description of Soil........................................................................................................................................................................ x U •-••----•-•-•--•-•-••--....•-••--------------••••-----•-•-•.........-•------•----••-...........••----------•---•--•••------•--•••-•-•-••----••---••-•---•-------••--------------------•---••-•---------- W ` ^- fin- - r 4/ ,x _' I U Nature of Repairs or Alterations—Answer wh n applicable _•-- __. •_-1"_..._-_--- / y r ,IQQQ f� �1�r1.._✓.__.---.__5A4Z........................................................................................... Agreement: _/ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee by the boar4 of health. Signedi ................. .l..-_.�/5.._ j ® Date Application Approved B I Date Application Disapproved for the following reasons________________________________________________________________________________________________________________ ...._..-•------------•--------------•----.....__...------------...--•---.....---------...-----------•----•••----••--•---•-----••----...•------•-•--•------•---•---•••••---••-•-------•-••-----•...-•---- _ Date Permit No.......T.s--- ............................ Issued_....... ... ---- ---•----------•---- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / Appliratiou for Disposal Works Tonstrtt.rtiun Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( 4<an Individual Sewage Disposal System at: ........ ..................................................... - t�---..... ------- r Location Address or Lot No. r.. ................+• - - .... ....--•----------------- Owner �t Address .. . .. Address •---•--•--------•---------------------•--------- Installer Address Type of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) .._..__._.__ Showers — a Other—Type of Building ..�. .�-:��'..'�"":_ No. of Persons...�....�1.�.... ( ) Cafeteria ( ) Otherfixtures -•-------------•------------•--------••--•-----------•-•--••---•-•------••••-•-----••--••-••---• .----------------•._...----------•-.----- WDesign Flow..................................:.........gallons per person per day. Total daily flow............................•_.._.__.__.__..gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width...........:.__..... Total Length.................... Total.leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below`inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by =......•"::..•••-•--••-••-•----•••••-•--••••-•- Date........................................ Test Pit No. 1...........:....minutes per inch Depth of Test Pit.................... Depth to ground water........................ fz, Test Pit No. 2................minutes per inch• Depth of Test Pit.................... Depth to ground water........................ •-----....--••---------•----------------------------------------------------------------------------......................................................... 0 Description of Soil....................................................................................................................................................................... x U ..............................................••••-••••-•---••-•-•--•-•--••-•.....--••-•-----•......--•-.......•-•-•-................................................................................. W -----------•----------•-•--•--......-•••-•---- - . --------•------------- .................................. 0 Nature of Repairs or Alterations—Answer when applicablefh , . �g".;�.!/" ~".,1 zc7$ s• ,� Agreement: a The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has id by the boa �;�f heath. Signed --••••..... e!.-R.. - Date .. Application Approved BY ��•-'--••-••-----•...._.._...-•••-••---•--••----•-•-••••-- --•-- f r3----- ........ Date Application Disapproved for the following reasons:•------•----------•----•-...................................................................................... .................••---••--........_....••••-••-•••--••--••--•------=........•----•---••••--•--......•--••--........---••••--•-•---------••----•-•••---••-•--•••....----•-•-•--•-----•-•••--••--•--••--•. Date PermitNo._.... .5 - Issued-----.-l._._-_a` S .-•-------•-••-- ----------�----•--- ---------- Date � � y THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....1�1. {......................OF.....tL,a.r{ "�r SQL.. Pik....................................... Trr#ifiratr of Toutpliaatrr THIS 15 TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( — at........ i7 4... --•----- ���......-- ------ ------------Instal� �/_.._.St��P{�----- ................................... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..........K5....1.................... dated...... ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......... ... .. .......8 ...................................... Inspector........ _ ............... . ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 �j" •W ...............OF.... .. /.. ''" +. .l4? P............................ No.:0. `... ..... Bispos al Iv. or p %-Konstrt Uan rrmit Permission is hereby granted.....ale., .//f.�F'_e"".o.. ---4�.............. to Construct ( ) on Repair (4.o an Individual Sewage Disposal System A at No. eAyf A TT— treeE � t-- •'. as shown on the application for Disposal Works Construction Permit No.__7�" ...... Dated..... ............... N ......................................... e.. ........................................... ......................................... oard of Health DATE............,.�"._�:..��_.�..._' ; FORM 1255 A. M. SULKIN, INC., BOSTON