HomeMy WebLinkAbout0919 MAIN STREET (OST.) - Health .G91.9 MAIINSSIT
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TERVILLE'
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Ps Form 3811,December 1994 102595-9�-B-orrs DomesticReturn Receipt
� ,. Town 'of Barnstable
BAPMAB�
�. Department of Health, Safety, and Environmental Services
039. Public Health Division
367 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas A McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
TO: CH NEWTON BUILDERS INC. DATE: JAN. 20, 2000
P O BOX 922
FALMOUTH MASS., 02541
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE,
TITLE 5.
The septic system owned by you located at 919 MAIN ST., OSTERVILLE was inspected on
02/11/97 by JOSEPH P. MACOMBER JR. a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the guidelines of
1995 TITLE 5 (310 CMR 15.00) due to the following:
1. The main cesspool blocks are badly deteriorated. '
2. Serious soil intrusion and rooting into overflow cesspool°which is made of,cinder blocks.
3. System size is inadequate to handle main building.
The above system, according to our records has been in a failed state for more than two years.
Therefore, you are directed to hire a licensed Town of Barnstable septic system installer to sketch
a proposed system that will bring the septic system into compliance with 310 CMR 15.00, The
State Environmental Code, Title 5 within(14)fourteen days of receipt of this notice.
The septic system must be brought into compliance within'(30) thirty days of your receipt of this
directive.
You are also directed to maintain the system by hiring a licensed septage hauler to pump the septic
system to prevent discharge of sewage or effluent into buildings, onto the surface of the ground, or
into surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to any court
of competent jurisdiction as provided for by the laws of the Commonwealth.
ZP O� HE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O. 3
Agent of the Board of Health
Town of Barnstable
q:heMthW11e9UWe52y.da - ,
TOWN OF BARNSTABLE
LOCATION q I G( 6 SEWAGE #
�O
VILLAGE O��r�/�'� � .P_ ASSESSOR'S MAP Cz LOT
INSTALLER'S NAME re PHONE NO.C -: , !'7f &- n , I n C.
SEPTIC TANK CAPACITY 15OD GLL�
LEACHING FACILITY:(type) WaO (Size) 500 C
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER •} N �� (� j��,���� �
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: / — x9,_
VAkIANCE GRANTED: Yes No �/
i
21 43 9
a,
0
33;s a,
v
3b�
`.►) D3 mil_'; �� D-3ak � (� ) M�d.�u� }� Cbv�er'
No. �4/ ;7� Fee `
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippIication for Mi5paal *pgtem Construction Permit
Application for a Permit to Construct( )Repair( ✓<Upgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. 719 Owner's Name,Address and Tel No �, p
Assessor's Map/Parcel t/10
Install ;'s Names`,and Tel No. / tDesigner's Name,Addres—amd Tel.No. `
TV.4 OWLS7_3(�
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building !4r,&d4-e- No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 316 C eZ) gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets 1;? Revision Date ^//,f
Title 1
Size of Septic Tank ism Type of S.A.S. .!09 A-19-i- ke� 166-s Z)
Description of Soil > r - d a �� �- Z zc),4�
P 6O`' Gy��S4 r��a o
Nature of Repairs or Alterations(Answer when applicable) / L- (- I- P-0 BOX- 11
Date last inspected:
Agreement:
The undersigned agrees to ensure the constKction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisi ns of Ti o nv' nmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu t oar of !rIt-Vq6
Sign Date
Application Approved b Date
Application Disapproved for the following reasons
Permit No. Date Issued
'No. �C✓ �/ 4P Fee /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEi MASSACHUSETTS
• Z(pprication for Mf-qpoga[ *p!6tem Con5truction Permit
Application for a Permit to Construct( )Repair( -,,,upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 1719 ArN� /e Owner's de, Crand
.N
Assessor's Map/Parcel �,`; ! %�Q• �' hZ AA
Installe 's Name,Address,and Tel.No. Designer's Name,Addres&and Tel.No.
r
Type of Building:
Dwelling No.of Bedroom" 's Lot Size sq.ft. Garbage Grinder( )
Other Type'of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures �e f •�
Design Flow ��� C r'�� gallons per'day. Calculated daily flow gallons.
Plan Date /U a S 9/e - Number of sheets a Revision Date ^�'¢
Title - }}
Size of Septic Tank /S� Type of S.A.S. 49& .� N 13E�(2)
Description of Soil �_ z LCJ�i✓/
Nature of Repairs or Alterations(Answer when applicable) /S_ZQ'E S• {��0 2)—,sOX iq,-,)
qq N!13eo�1` w /2 X 2-5-
j
Date last inspected: 'k
Agreement:
r
The undersigned agrees to ensure the constrKction and maintenance of the afore.described on-site sewage disposal system
in accordance with the provisions of Tit of a vi nmental Code and not to place the system in operation until C rtifi-
cate o,�Compliance has been issued-by t ` oar , f h. '
Signed / Date
Application Approved b Sc'r - Date
Application Disapproved for the following reasons t
r
Permit No. 1 7 Date Issued
J
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS F;
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( )
Abandoned( )by_ _ ®� Gs 4�s
at Gl / A" 1 has been constructed in/accordance
92'
with the provisions of Title 5 and the for Disposal System Construction Penn it No. ��*dated
Installer Designer
t The issuance of this permit shall not be construed as a guarantee that the syste . will function as designed.
Date 1 _" Inspector
----,—_—�r—'—----------==--------- /
No. 9 ' 7/ � _—==--=Fee r w 1�^
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
If6poal *pgtem Construction Permit
Permission is hereby ranted to Construct( )Repair( ) grade( 4-)`Abandon, )
System located at V� //�/!f S _ U� ,.J 7f-7/-,,'
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of thiss�it.
Date: ���' / Approved b -'G �' i �wi '
11
�-y
WATU R
SERVICE _
F.F.
iLty, 39.h1 I /
EXIST. WOOD
FRAME /
AR1VCwAY z
I � I DUILDINGSEWER
a TO BE CAST 1 RoN
log 12� o I W I I / �.
/ I I O 1 tt F.F EL1a V. / ' N
I '� O
b0 L.__j _ �/L. 1 @ WATER I
/ I- EXIST, WOOF SERVICE I/ I
W Y
0 FRAMG
0
0 I OAS E.FF. ELEV, /
'67.10 I
K71SEPTIC I— I
/ D-BOX TANK 160
DEEP I
HOLE
M a 1
Z N DRIVEWA'y t =
W
PLAN VIEW
Scale:I = 20'
p�EP NOL� EL,3 9.O
O
FI LL/14ARD PACK
ORGANIC/LOAM
ROOTS
E DRowN COARSE SAND
STRONG GROWN
[i COARSE SAND
CI B HROWNIS YELLOW
COARSE SAND
�a I-MI-IT YELLOWISH BROWN
Cz COARSE SAND
• DEC-P 1- 0LE RUGGED ON
1 o/28/9 8
No wAT%K E>rcouKTEp SITE PLAN
SEPTIC SYSTEM UPGRADE
AT
919 MAIN STREET
OSTERVILLE, MA
FOR
C.H. NEWTON BUILDERS
Assessors Map 117 SCALE:AS SHOWN DATE: OCT.28,1998
Parcel44 SULLIVAN ENGINEERING INC.
SHEET I Of 2 OSTERVILLE MA
1` y
QOTES DESIGN DATA
L Water Supply ForThis Lot is Municipal Watec Office Sp ace=75 G.P.D./1000 st l
2774 sf/1000 sf=2.774 x 75=208 GPD
2 Location of Utilities Shown on This Plan Am Approx. I Bedroom= 110 GPD
At Least 72 Hours Prior to Any Excavation ForThis Total Daily Flow 318 GPD
Pro{ed The ContractorSholl Make Ths Required Septic Tonk: 318 GPD x 200%=636GPO
Notification to Dig Safe(1.800-322-4844) Use a 1500 Gallon Septic Tank
3 The Contractor is Required to Secure Appropriate
Permits From Town Agencies For Construction LEACHING AREA
Defined byThis Plan. 318 GPD/0.74=430 SF Required
4 Install Risers as Required 10 Within 12"of Sidewoll s 2(12�25')2 a 148 S.F.
Finished Grade. Bottom Area=12'x..25' = 300 S E
5.All Structures to be H-20 Loading 448 S.F.Total ProvidedLEACHING CHAMBER DESIGN
6. Septic System to be Installed in Accordance With All 2;50 Go lion Leaching ChombersIna
Bar 12x 25 0 Pippees to be Schedule 40.Use
CMR 16.00 Latex!Revision And The Town of Wash Stone Field as Shown.
Barnstable Board of Health Regulations. .
7. All Piping to be Sch.40 PVC,Except as Noted.
Heavy Duty(H-20)Frame 8�Cover'
toFlnishGrade F.G.39.0
x 36.0
Top EJ.37.0
36.8 1500 Gal. 36.6 Bof.EI.34.0
Septic Tank 36.4
• %J Bedding as 510�
Per Tills 5 12 0
10.5! 10, 1
Bottom of T@et Hole Elev.
it InvAbMainBuilding=38.0 29.0,GroundWater(d)Elev.
Inv.4Rear Building=37.4 Less Than 5.0 as Per TQB.
Ground Water Map.
DEVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM •
Not to Scale
Finish Grade
Filter
r3
Fabric ��Compacted Fill-
as
Pea Stone
0) 77
'v Chamber. Leaching 3/4"-1 1/2"Double
a Washed
I 4!-I I
d-O"
CROSS SECTION OF CHAMBER
•SNOT TO SCALE
Assessors Map 117
Parcel 44
919 MAIN ST.
OSTERVILLE,MA
SHEET ?- Of 2
TOWN OF BARNSTABLE G C'
LOCATION M ai rl 5 'Ce,,-t SEWAGE #
VILLAGE OSLerV),I I P _ ASSESSOR'S MAP & LOT +D
INSTALLER'S NAME 6i PHONE NO. n C.
SEPTIC TANK CAPACITY S0D GG_U6 n ,S
�I LEACHING FACILITY:(type) fitoZO (size) SOO
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
I
BUILDER OR OWNER C {� . N�i ylnr g), � 9�f. z
DATE PERMIT ISSUED:
1
DATE COMPLIANCE ISSUED: - -.9, -
y
VARIANCE GRANTED: Yes No /
I
i
1
20 43
33 S a�
yJ _
3`5,5
i '
rsoo gai. 44-ao
/a) $OQ, gat. •' (Pctl �r,9 Gm6cf-s
- 1 C
TOWN OF BARNSTABLE
( � Cc �1 Sf,-'cam
LOCATION SEWAGE #
VILLAGE O_,��ety ASSESSOR'S MAP LOT
i
INSTALLER'S NAME & PHONE
SEPTIC.TANK CAPACITY I Soo GG.���n ,S
I LEACHING FACILITY:(type) (size) 500 GI L
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
Ii
BUILDER OR OWNER C }� Iu ct�) (l t )a
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
—._
— -
�1 49 �g
0
33S s� f
I�
f
i
riser
+) ao (� 4 .ct o r� 5c rs
S Sai. s.f !a) µao $ G
:: -�„�t .. I Pu��, r,9 t hr� •,be r5 �
'��►�a o p_3�x ( 1 Mid .�o�t� �� C.over � .. -
01�
•
d.
DATE: _2/6/97
PROPERTY ADDRESS: 9-19 Mki-n Street
E
Osterv.ille ,Mass . B 2 10
or 9
02655 '01r D rAecf
4 Q Q
6
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . 1 -4141 .block cesspool/
1 -41x6l Block cesspool.
Based bn my InRnectlon, I certify the following conditions:
1 . -The main cesspool 4 'x4' is badly deterrorated. Blocks
are partially gone . Previous acid treatments over the years .
. 2. The overflow cesspool is made from cinder blocks on
there sides . Serious soil intrusion and rooting. . .
3 . System is totally inadequate to handle size of main builing
and separate apartment detached.
4. System is in failure .
5 . Must be upgraded to a title five
septic system. '`~ _SIGNATURE:
Name:-J . P.Macomber -Jr... i
Company:'-- &-
Son-_Inc . ;
Address:_.�ax-66-----=�-- -- �
__Cen terville , Mass__02.632
Phone: � �
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
LS. P. MACOMBER & SON, INC.
Tanks-C�sspoolrLoschtields
Pump♦d Q Ins411ed
Town Sewer Connectlons
x 66• Centerville, MA 02632-0066
775-3338 775-6412
Ul
Commonwealth of Mossachusetts
Executive Office of Environmental Affairs
Department of
environmental Protection
Trudy Core
s.r__y
David
0..�s�truuhs
U.Gowl,,. COrtvnreerona
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Addreaa: 919 Main Street Osterville ,Mass Address of 0evner. David Newton
Date of lnapewtlon: 2/6/97 (If dlffereat) Box V
Name of lnopector. Joseph P.Macomber Jr . Falmouth,Mass .
Company Name,Addrear and Telephone Number.
J.P.Macomber & Son Inc. Box 66 Centerville ,Mass . 02632 508-775-3338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this addreaa aced that the information reported below is true, aocurat.a
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site "wage disposal systems. The system:
Passes
Conditionally Passes
_ seds,F-urther Evaluation By the Local Approving Authority
C` Fails
Inspector's signature s( C Date: , l�-9/
The System Inspectors submit a copy of this inspection report W the Approving Authority within thirty(30)days of completing this
inspection. It the 67rtem is a shsred system or bas a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner rind copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A. B, C, or D:
A) SYSTEM PASSES:
zt&) I have not found any information which indicates that the ryrtem violatas any of the failure criteria as defined in 310 CUR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
- � One or more system components used to be replaced or repaired. The system,upon oompletion of the replacement or repair, passes
inspection.
Indicate yea, no, or not deurmined (Y, N, or ND). D"cribs basis of determination in all instances. If'not determined',explain why sot)
The septic tank is meta),cmzked, structurally unsound, shows substantial infiltration or exliltration,-or tank failure is
imminent.The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by tL. Board of Health.
(revised 11/03/95) 1
One Winter Suest a Boston, Massachusetts 021N a FAX(617) 556.1049 a Telephone (617)292.5500
�� PmiWon R cycled Pepe
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Addree- 919 Main Street Osterville ,Mass . 02655
Owner. David Newton
Date of Inspection-2/6/9 7
B)SYSTEM CONDITIONALLY PASSES (continued)
bye- Sewage backup or breakout or ho static water level observed in the distribtttbn bca ii due to broScsa or obstructed pips(s)
or due to a broken, settled or uneven distribution bar. The system will pail iaspoation'if(with approval of the Board of
Health):
broken pipe(&)are replaced
obstruction is removed
distribution boat is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH-
NO Conditions exist which require further evaluation by the Board of Health in order to determine if the system is tailing to protect tha
public bsalth, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
40 Cesspool or privy is within 60 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 APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT`.
The system has a septic tank and oil absorption system and is within 100 feet to a surface water supply or uemtary to a
surface water supply.
/o The system has a septic tank and oil absorption system and is within a Zone I of a public water supply well.
.120 The system has a septic tank and oil absorption system and is within 60 feet of a private water supply well
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply wig unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the wall is free
from pollution fmm that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or lass than 6 ppm.
3) OTHER
2-cesspools . 1 -4 'x4r & 1 -5 'x6l • No to Paragraph 2 *section C
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Prop.rtyAddrwa: 919 Main Street Osterville ,Mass .
Owner. David Newton
Date of Lnspootlon: 2/6/97
Dl BYSTEM FAILS:
1 have drtarminad that the system violates one or more of the.following failure criteria u dadmad in 310 CUR 16.303. The basis for
thi, datarmination is identified below. The Board of Health should be oontaeted to detarmins what will be aao.saary to oorrect the
failure. '
,de:p Backup of sewage into facility or ryrtem component due to an overloaded or clogged SAS or cesspool.
�U Discharge or poading of eMuent to the surface a the ground or surface waters due to as overloaded or clogged SAS or
cesspool.
Static liquid level in t, --a.tribution box above outlet invert due to an overloaded or clogged SAS or aupool.
Liquid depth in oesspoo}is lea than 6'below invert or available volume is less than lfl day flow.
A)p Required pumping more than 4 tunes in the last year NOT due to clogged or obstructad pips(s).
Number of times pumped
[�Q Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
i{I(� Any portion of a cesspool or privy i, within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 60 feet of a private water supply well.
N� Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water aaalyais for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAIL9:
The following criteria apply to large systems in addition to the criteria above:
The system served a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a aignificaat threat to public
health and safety and the environment because one or more of the following conditions cdst:
4 LA the rystam is within 400 fast of a surface drinking water supply
& the rystam is within 200 feet of a tributary to a surface drinking water supply
I the rystam is located in a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA)or a map
ped Zone II of.public
water supply well)
The owner or operator of any such system shall bruit'the rystem and facility into full compliance with the prvundwatar treatment program
requirsmanu of 314 CMR 6.00 end 6.00..Please ooruult the local regional ofllce of the Department for Authar information..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
p=.op61Y,zd,..a 919 Main Street Osterville ,Mass .
owner. David Newton ,
D&W of Inspootion: 2/6/9 7 '
Cback if the following have been dons:
ZPumplag information was requerwd of the owner, ooupant, and Board of Health.
one of the system compoww;ts have been pumped for at least two weeks and the system W been receiving normal flow rates
during that period. Large volumes of water have not booa introduced into the system reaa90 or as past of this inspealaa
As built plans bave boon obtained and examined. Note.0 they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
7-- The site was inspected for signs of breakout.
:IA11.sysum components,eluding tb. Soil Absorption System, have been Iocated on the efts.
AYA,Ths septic teak manh lei were uacavered, opened, and the intarior of the saptic tank was inspected for condition of be fn or
Leer, taatarial of construction, dimensions, depth of liquid, depth of sludge,depth of acum.
ZT1. size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods,
ZThe facility owner(Lad occupants, if different from owner)were provided with information on the proper taatatenaace of Sub-
Surface Duposal System.
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddresa: 919 Main Street Osterville ,Mass .
Owner. David Newton
Date of Inspeotiow 2/6/9 7
FLOW CONDITIONS
RESIDENTIAL-
Design flow , � � �, :-a4y
Number of bedrooms:-
4-Number of au wA residents:
Garbage grinder(yes or no):,4
Laundry connected to system(yes or no):M
Seasonal use(yes or ao): 2
Water meter readings, if available: QC /. �
hJEf
Last date of occupancy: r i A
COMMERCIAL NDUSTRIAL-
Type of estab' hment:
Design flow: j ons/day
Grease trap present: (yea or no)/0
Industrial Waste Holding Tank present: (yea or no) Ld
Non-sanitary waste discharged to the Title 5 system: (yea or no)
Water meter readings, if availAle•
Last data of occupancy:,�
OTHER: (Descnle)
Last date of occupancy: A)
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)___() Sy>i�yl�f
If yes,volume pumped: ea—)Ions
Reason for pumping: /I)
TYPE OF SYSTEM
/ Septic tan.Vdist.rzibution boxlsoil absorption system
Singie oseapool 4"XIV, ;
Overflow ce p.1
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
,,V Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C• •
SYSTEM INFORMATION (continued)
Property Address: 919 Main Street Osterville ,Mass .
Owner: David Newton
Date of Inspection: 2/6/9 7
SEPTIC TANK:A,'a e .
(locate on site plan)
Depth below grade:
Material of construction—V. concrete _metal _FRP —other(explain)
Dimensions:_
Sludge depth:
Distance from top of sludge to bonom of outlet tee or baffle:AZL
Scum thickness: w n
Distance from top of scum to top of outlet tee or baffle: 4�
Distance from bottom of scum to bottom of outlet tee or baffle,—
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffle,. depth of liquid level in relation to outlet invert, structural
•rity, evidence of leakage, etc.)
eptic Taiik is not present .
GREASE TRAP. fe4f—
(locate on site plan)
Depth below grade:,
Material of consui!rtion-tr�:oncrete _metal _FRP —other(explain)
Dimensions
Scum thickness:/1
Distance from top w scum to top of outlet tee or baffle:_IJa
Distance from bonom n( frum i- bonom of owlet (PP or bafle,. 2.
Comments:
(recommendation for pumping, condit-n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, elc.L_T,
Grease trap is not present
s
(revised 1/1$/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (000tlnued)
propertyAddrou: 919 Main Street Osterville ,Mass .
Owner. David Newton
Date of Insp"Llon: 2/6/9 7
TIGHT OR HOLDING TANI(sdd?f--
(boats an di•plan) •
Depth below Vads:,,&2
coa Matarlal of st:u , J#ooaarte_mstal_FRP_othar(aplLW
Dimaarlous: 10A �
Capacity us
D.at,t flow oas/day
Ahem level•
Commaata:
(ooaditloa of ialst tee, oonditioa of alarm and a"t switch", etc.)
Tight or HolinR tank not present
DISTRIBUTION BOX/ q.4/e,.
(locate oa site plan)
Depth of liquid level above outlet invert: ,&'
Comments:
(cote if brval and distr tion is equal, evidence of solids carryover, evidaace of leakage Into or out of bo:,etc.)
Distribution box is not present
PUMP CHAMBER:�/II'�i
Gocate oa site plan)
Pumps in worliny order.(yes or no)_,224
Comnutate:
(cote coadition of pump chamber, oondWoa of pumps end appurtauaaow, etc.)
Pump Ghamber is not present
(revised 11/03/95) 7
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Properhwddreas: 919 Main Street Osterville ,Mass .
Ow"r. David Newton
Date of Lapeotl= 2/6/9 7
SOIL ABSORPTION SYSTEM (SAn-z
Goes"on rite PILO.if posy excavation not required,but may be appr=imated b7 non-bams v metbods)
If not determined to be prwat,.:plain:
T}P-
P4 number
Clambers, number:
gallaries, number
la"hing treacles, number.langt L
leaching Salds, number,dimes
over
flow ossapool, number
rns
Command: (note condition of soil,signs of hyossuuc failure, level of Popdir:P,ogadition of ve¢e�atigr�ete)
Medium sand to fine sand : No signs of Wy raulic _I-ailur or on in .
All ,. o+o+; nr, ; c normal T ; t+lo nr nr nn nGP for the pant two years
D`Fe1' l ntis 1� f E: 6� }.Llfl.^IGS nn +hero ci r�a�+ 4�'ni Rr root ;o
CESSPOOLS: `intrusion. _
(locate on site plan) _
Number Lad oonSgurLtioa ; '
Depth-top of liquid to inlet invert:
Depth of solids 1a,Yar
Depth of scum layer. _
Dimensions of ces& E-4
Hatariala of construction:
Indication of VvUndwatar
inflow(owspool must bs Pumped as Part of inspection)
Comments: (note condition of ofhydr �l:c failure level of
Medium sand to fl e sat�da:',1�To signs o 'yc° rau- 1c ?a' 1'uVe or ponding.
11 ve e a ion is norms ain cesspool is 15reaKing up.,,Ileavy__�Lutd
in the past. System must be upgraded to a i e 1ve septic system.
PRIVY:�j_)C,d/V. ----� � � - -- -- _ -.-- - ------ -
Uocats on site plan)
Material&of
Depth of solids '
Comments:(note oondition of&oil,signs of hydraulic failure, level of pondin&condition of v*g*tation.its,)
� r
y •
(revised 11/03/95) g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INBPECTION •FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE E=SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
Centerville Osterville Water Company
428-6691
o CIO -
O �
I
I
,4 IA-, s r o s'r—
DEPTH TO GROUNDWATER
r 161 + depth to groundwater
rAthod of determination or approximat�op:
�zr' _ ,
ns a e se - • e o Gallery- Pace
no water en66-uint7e
TOWN OF Barnstable BOARD OF 11EALTII I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
�� F-•m-.••.-tt--.,,r.-.-.rr.rir+n•rrrrtra+r�srrr+T-r-,.•vr+r-�arn+vr-r..ma+sY s.n r.+vrr•r-�.—..�
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS _919 Main Street Osteryille ,Mass .
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME David Newton
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & S61' *Inc ,
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632.
Street Town or City State LIP
COMPANY TELEPHONE ( ) - 3338 FAX ( )
508 775 508 790 1578
W
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true , accurate , and
complete as of the time of ,inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Check one :
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
healLh or the environment as defined in 310 CMR 15. 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
X� XXXXXXXXXSystem FAILED
The inspection which I have con acted has found that the system fails to
protect the j-)ublic health and the environment in. accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date2/11 /97
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEAL1`II.
* If the inspection FAILED, the owner or"' parator shall upgrade
within one ,year of the date of the inspection, unless allowed ort required
he m
otherwise as provided in 3.10 CHR 16 , 305 .
partd .doc
HM ] 11 H E A L T H M A S T E R ] HELP [ ]
R E C 0 R D ] ACTION I] .
For Parcel Number 1171 0441 0011 ] Rental Property(Y/N) [ ]
Owner Name DLN LLP ] Zone of Contrib (Y/N) [ ]
Location 919 MAIN ST OST ] Contaminant Rel (Y/N) [ ]
Business Name [ ] Area Number
Contact Person [ ] Phone [000] [ ]
Fuel Storage Tank Permit [ ] Card on File [ ]
Perc Test Well Septic
File/Permit No. [ ] [97-462 ] [97-236 1
Issuance Date [0827971 4-TO-5-14-97]
Completion Date [ ] [ ]
Last Communications [ ] (MMDDYY)
Comments [REPAIR- 1500 ST, 3 CULTEC RECHARGERS ]
Cancel [ ]
NEXT SCREEN [HM ] ACTION [ ]
PARCEL NBR [ ] [ ] [ ] TANK NBR [ ] ]
�,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property
Owner ' s name J"' A
Date of Inspection
PART A AUG 2 5 1995
CHECKLIST RMNDE"�
Check if the following have been done : TM OF BARNSTA8IE
N}_ Pumping information was requested of the owner, occupant, and Board of
Health.
None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period . Large volumes of water have not been introduced into the
system recently or as part of this inspection.
ILA_ As built plans .have been obtained and examined . Note if they are not
available with N/A .
_ The facility or dwelling was inspected for signs of sewage back-up.
's
`I'he site was inspected fo,r signs of breakout .
A�l system components, excluding- the SAS , have been located on the
-- site . I
C ass �
The manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid , depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods .
V The facility owner (and occupants , if different from owner) were
provided with information on the proper maintenance of SSDS .
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
05,V0393fi FLOW CONDITIONS
If resi. ential
numb-era`Eo' " a O_...� currnt esidents
number—p�f_. t.�_ er
K16 garbage grinder, yes or no
laundry connected to system, yes or no
'usS seasonal use, yes or no
If nonresidential , calculated flow:
Water meter readings , if available:
Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
System pumped as part of inspecti n, yes or no
if yes, volume pumped l k _
Reason for pumping : 105 C 7�, R
Type of system
Septic tank/distribution box/soil absorption system
—t� Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) ( if yes, attach previous inspection
records, if any)
other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
14
a odo
rs
arriving at the site, yes or no
Sewage dete
cted when ar g
�_ g
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: UONZ
(locate on site plan)
depth below grade:
aterial of construction: concrete metal FRP other(explain)
dimensions•
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
omments:
(recommendation for pumping , condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
vidence of leakage, recommendations for repairs, etc. )
ISTRIBUTION BOX: IJON F-
(locate on site plan)
depth of liquid level above outlet invert
omments:
(note if level and distribution is equal , evidence of solids carryover,
vidence of leakage into or out of box, recommendation for repairs, etc. )
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs, etc. )
10
r'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
( locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool , number
Comments:
' (note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, etc. )
flu.h►v£. Q£� I\£
CESSPOOLS ( locate on site plan) : 1
number and configuration .7 Al
depth-top of liquid to inlet invert
depth of solids layer O —
depth of scum layer
dimensions of cesspool OG
materials of construction ^r Rig
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, etc. )
rn v R S
err wo u � J o N aN
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, reco
mmendations for maintenance or repairs, etc. )
. 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent -references landmarks or benchmarks
locate- all wells within 100 '
A
cFsVwIs
39 ' ► 3�
J
iV �
DEPTH TO GROUNDWATER
a3-3 E� depth to groundwater .5R°m °ern O f
method of determination or approximation:
V•S- 0 0 i c A1 C7 u , u-6 0 A N M:d
i
Lcl�' fvIv zeme C . h
12
r
SUBSURFACE SEWAGE
DISPOSAL SYSTEM INSPECTION FORM °
PART C
FAILURE CRITERIA
i or ND) . Describe basiso )
Indicate yes,
no, or not determinef (not determ
determination i ined" , explain why
n
n all instances.
Backup of sewage into facility?
Discharge or ponding
of effluent to the surface of the ground or
surface waters?
Nl� l
in the distribution box above outlet invert?
Static liquid leve
<6" below invert or available volume< 1/2 day
Liquid depth in cesspool
flow?
n the last year?
Required pumping
4 times or more i
number of times pumped -_---
structurally unsound? substantial
ank is metal? cracked? tank failure
7— infiltration? su imminent.
Septic t
" bstantial exfiltration?
ortion of the SAS , cesspool or privy :
Is any p elevation?
below the high groundwate r
jL within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface
water supply'•
within a Zone I of a public well?
feet of a bordering vegetated wetland or salt marsh
j_ within 50 not the SAS) ?•
(cesspools and privies only ,
within 50 feet of a private water supply well?
private water
less than 100 feet but greater than 50 feet from
analysis? If the well
from a
supply well with no acceptable water quality
copy of well water analysi
has been analyzed to be acceptable, anic compounds, ammonia nitrogen
for coliform bacteria, volatile org
and nitrate nitrogen.
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector 0_6Rg1orj �qUr'Jous
Company Name DcZRN ZN&►2 A( C G.
Company Address J` ��dx C,69
I - WaB�6w �
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
C ck one
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15 ..303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15 . 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form.
Inspector ' s Signature
Date g/8/9J5
Original to system owner
Copies to:
Buyer ( if applicable)
Approving authority
Parcel Detail Page 3 of 3
i
i 16 1997 $52,700 $0 $0 $129,800 $182,500
17 1996 $52,700 $0 $0 $129,800 $182,500
18 1995 $52,700 $0 $0 $129,800 $182,500
19 1994 $60,300 $0 $0 $138,000 $198,300
20 1993 $60,300 $0 $0 $138,000 $198,300
21 1992 $68,800 $0 $0 $153,400 $222,200
24 1989 $119,200 $0 $0 $221,200 $340,400
25 1988 $66,700 $0 $0 $110,100 $176,800
26 1987 $66,700 $0 $0 $110,100 $176,800
27 11986 1 $66,700 $0 $0 $110,1001 $176,800
Photos
IA
- ..4/i... _ '� � R _ �.♦ •� Fob ,r3 i
�K
9/ 9
)n a
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=6749 9/8/2011
Parcel Detail Page 1 of 3
9� Lj
H
EAA15TA141.F_
Logged In As: Parcel Detail Thursday,September 8 2011
Parcel Lookup
Parcel Info e -
Parcel ID 1117-0 Developer LOT 1
l Lot l
Location 1919 MAIN STREET(OST.) l Pri Frontage l
Sec Road r` l Sec
l l Frontage
Village,OSTERVILLE l Fire District C-O-MM l
Sewer Acct l Road Index 10953 l
r`,
Interactiveti y;{
Map
- Owner Info
Owner JDLN LLP _ + Co-Owner CH NEWTON BUILDERS INC l
Streets 198 N WASHINGTON ST-SUITE 202 l Street2 l
City BOSTON l State�M zip 02114 Country
- Land Info
Acres 10.17 Use OFFICE BLD MDL-94I zoning 1BA J rvghbd,C6
Topography l Road
Utilities l Location — l
- Construction Info
Building 1 of 2
Yearr1732 l Roof "' I Ex WOOD FRAME l
Built Struct 1 Walll
Living4" Roof l AC HEAT ONLY
Area; Cover Type
IntVIM
Style Office Bldg l Wall l Rooms L _l F '
aas
Int Bath WIS
Model'Commercial i Floor Hardwood Rooms
1 Full s .
Grade fCUstom l Heat Total r
Type Fl Rooms '
F��S
stories�� l Heat r Gas Found- St6ne Walls l �
Fuel ation
Gross r3336
Area
Building 2 of 2
Year F'965 I Struct' Wall Roof! Ext
Gable/Hip all►Clapboard
I
Built
http://issgl2/intranct/propdata/ParcelDetail.aspx?ID=6749 9/8/2011
Parcel Detail Page 2 of 3
Living 308 Roof Wood Shingle--I AG None �I
Area• - I Cover Type
F--- -- - - Int`�Drywall
"-_" I Beds_
Style,Cottage I wail)Dr wall Rooms
Int - Batn
Floor RoomsModel FRe-dential 1 Full
AS
Total
Grade;Average -I Type;Elec Baseboard I Rooms 2 Rooms I �P'
Heat Found- 4:
Stories,1 Story T I Fuel(Electric I ation Conc. Slab
Gross Area(336 YI
Permit History
Issue Date Purpose Permit# Amount Insp Date Comments
05/14/2002 Remodel/Renov 61067 $20,000 01/01/2003 00:00:00
11/25/1997 Remodel/Renov 27358 $20,000 01/01/200100:00:00
Visit History
Date Who Purpose
04/17/2003 00:00:00 Gary Brennan Bldg Permit Completed
08/13/2001 00:00:00 Gary Brennan Meas/Listed-Interior Access
03/31/1998 00:00:00 Lloyd Kurtz
05/15/1991 00:00:00 ME
Sales History _
Line Sale Date Owner Book/Page Sale Price
1 05/29/1997 DLN LLP 10771/264 $1
2 04/04/1997 C H NEWTON BUILDERS, INC 10684/106 $140'000
3 05/15/1988 DOWNEY,WILLIAM J&MARY A 6247/106 $1
4 11/15/1983 DOWNEY,WILLIAM J TRS 3923/034 $125,000
5 10/15/1983 1RIEDELL, $125,000
Assessment History
Save# Year Building Value XF Value OB Value Land Value Total Parcel Value
1 2011 $276,400 $3,200 $0 $357,900 $637,500
2 2010 $276,400 $2,600 $0 $357,900 $636,900
3 2009 $273,900 $2,600 $0 $395,200 $671,700
4 2008 $238,600 $2,600 $0 $395,200 $636,400
6 2007 $267,000 $2,600 $0 $395,200 $664,800
7 2006 $267,500 $2,600 $0 $395,200 $665,300
8 2005 $247,700 $2,600 $0 $300,500 $550,800
9 2004 $222,200 $2,600 $0 $300,500 $525,300
10 2003 $159,300 $0 $0 $213,500 $372,800
11 2002 $159,300 $0 $0 $213,500 $372,800
12 2001 $125,700 $0 $0 $213,500 $339,200
13 2000 $83,600 $0 $0 $129,900 $213,500
14 1999 $81,800 $0 $0 $129,900 $211,700
15 1998 $81,800 $0 $0 $129,900 $211,700
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=6749 9/8/2011
TOWN OF BARNSTABLE
L ON �� y SEWAGE #
VIIL:�:�? t ASSESSOR'S MAP & LOT
—TOMP -U-MR''S'NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) J
NO. OF BEDROOMS_ 1
BUILDER OR OWNER �y
DATE: ?Z COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility , Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facili (If any wetlands exist
within 300 feet f leaching f ill / Feet
Furnished b ��
t
o �
e ,
b''
r
9/,9 '44 14 /P s r n SIT
7LC
ION SEWAGE PERMIT NO•
E
-r v f,�LLER'S NAME `g ADDRESS
� YC1 �� hSi
i
e UILDEIII OR OWNER
')77 o Ys
DA T E PERMIT ISSUED
4
DAT E COMPLIANCE ISSU-E-D
5� T. f
jQS
1 � I
No..�3..s�.. .« FEB....tJ ..............
THE COMMONWEALTH OF MASSACHUSETTS
�- BOARD OF HEALTH
- /�sGe�/l.J.........OF.... - ..............................
Appliratiun for lliipunal Workii Tunitrurtiun runfit
Application is hereby made for a Permit to Construct Xor Repair ( ) an Individual Sewage Disposal
System at:
............. __....... 1 -7......... -- :.........................................................
_
Locati ddre r N
AddressOwner
...
� Installer Address •�
d Type of Building AA [Z"rl� E ,,—Address
Lot._.__ .✓I...g7...Sq. feet
aDwell' —No. of Bedrooms_______ ______________ .Expa�sion Attic ( ) Garbage Grinder ( )
p, Other Type of Building . of ersons............................ Showers ( ) — Cafeteria ( )
a they fixtures .. ............
---------•-------------------------------•-------_..._---------....... .--- -------
d .. 1 ns. t�
W Design Flow.."-?.`�- -�z -- � _� � C f1Pt y- Total dayly flow.......... --_- 1�
WSeptic Tank—Liquid capacity-�OC4allons Length... ..- __ Width_ `-� _ Diameter................ Depth.. .._..e
x Disposal Trench—No..................... Width._ ak
..... Total Length....... T�ptal leaching area....................sq. ft.
3 Depth below inlet_... l'otal leaching area. �. _sq. ft.
Seepage Pit No....___._/..._.__.. Diameter.._...
z Other Distribution box (��� Dosin tank ( �44�DatePercolation Test Result Performed by._ - •:. /. ••- -3........
,� Test Pit No. 1....�.7-minutes per inch Depth of Test Pit.......�.�r <_._. Depth to ground water__________U.:-9-1-
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
t --•--• ....
O Description of Soil•----- f✓ �!' SJ. ..
:: 1
c, ---- �--� _ :-- - -- - --- -----------
••••------------------------•------•--------•-----------•--•------------•... -•--------•------------------------•••--•------...----=--------------•----•-----------.•-•-•-----------------.....
UNature of Repairs or Alterations—Answer when applicable._____________________________________•___.____.--_-.-------_-_.__...--------_--------.-.-..--•.
-•--••-••-----•---------•---------------------------•---------•--•----------....---...............•.---•---------•-------------------------------•------------•••........_...-----...._.......--•------•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT E 5 of the State Sanitary Cod — he undersigned fur her agrees not to place the system in
operation until a Certificate of Compliance has been su e o d. lie h
grie ..............•••...
Da
Application Approved By..... s .." --•-•--•--•------------------•----••---•-•••... �Z --�?.........
Date
Application Disapproved th following reasons:-•----------------------•--••--•------------------------------•----•--• ........................................
--••-•-•-•-------------------------•--•....•--•- ---•-•-•---••--•--••---•---••------•---•--•------•----•--------•-•---------•---------•---------•----
-------------- - -
Date
PermitNo......................................................... Issued-.......................................................
Date
--- -Fss....... o..............
THE COMMONWEALTH OF MASSACHUSETTS
�..- BOARD.OE HEALTH
....----`-•--............................ ........................J...,..................._......_...........................__.__
Allpliratiura for 11iupuuFal Works Tomitrurtivat erutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: �-
%. �. 1. /a?f r 1 / /�x fJ _ f" -
Location,• dress r^ r ,or Lot No,_• "! /
ra n✓'?{ Gam! � f '! /.............................................................
Addressf /=%l / • -�! A l�
t
......... ; .._......._ .~....... ............................. .........
......
Owne� ��
a 1 ---•------•--•- ----
�..4....:.................
Installer Address -1.--
Q Type of Building P . �% T I�� 1- ��TSize Lot......... ._. ".......Sq. feet
Dwelli —NO. of Bedrooms.._._F�r.....R .,,,,i. pansion Attic ( ) Garbage Grinder ( )
Other T e of Building No. of/e�rsons............................ Showers ( ) — Cafeteria ( )
a YP g = --------&
Qther fixtures --#......-••••-•. ---- --------------------------------•••-•--•------------................ ..
W g ®- � n ner ay. Total daipy flow..----------•---- ��``__ .,
Design Flow_. ` . !' !-I _ :�?• ...... ..�alI ns.
Ri Septic Tank—Liquid capacity---.,r.11gallons Length___ _ = Width. .'. Diameter................ Depth... ...
Disposal Trench—No..................... Width....:^.1........ Total Length............-:;.. ptal leaching area....................sq. ft.
Seepage Pit No.......... ...�_-- Diameter........= " Depth below inlet..... ;::a...... otal leaching area-.7ff_��.sq. tt.
Z Other Distribution box (I—) Dosing tank ( t ! /
-z
14Percolation Test Result Performed by..' :..�:_.-Al �_:!_..��........_`% :._'. :... �'s-Date.._.._. .! .. :?........
aTest Pit No. I....._-:-.-7-minutes per inch Depth of Test Pit----0_1..- Depth to ground water---_-__G_s_ :........ (;d
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-_________-----._--_---
O Description of Soil '' f I r / -� f i ~=f =`= C f ' y- - ,'' -.. - ` 1..t='.%:...
U ..........•..... ---- ; 77----.... /... er.._..:f ....
42
W ........................................................................................................................................................................................................
UNature of Repairs or Alterations—Answer when applicable................................................................................................
................................................•-•----------•-•------------------.....------••--•-•--...----------------------•-------•----------................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State-Sanitary Cod — he undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued-by the o d of�he th�
gne ` '.?`'.:.%:.!......... if .:'.... .........
.
Application Approved By... . --••--' �! ----------------------------•---•----....---•-------------..•----- ------/. � ,r; ......---
Date
Application Disapproved f th following reasons:......................................-........................................................................
........................................... •---••--•--•-•••......••--•-••--•---•--....----------•-•---------•----------------------
---------------------------------- ------ -
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................:...................OF.....................................................................................
up rrtifiratr of ToutpliFattre
pqn IS/0 NFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by_ ......._.1 V
..............................- ..........._..._
InstalLaK
" =. ... .
has been installed in accordance'with the provisions of TIT ,~ 5 of The State Sanitary Co .`as escribed in the
,,.��'
application for Disposal Works Construction Permit No...-�--, m. .� ............. dated_ _-/ __-_6.�.......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE
SYSTEM PI. NCTION SATISFACTORY.
DATE.... Y�..--•---.......-•-----•--•---••-•...................•---- Inspector.... l
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ry
...........................................OF.....................................................................................
No.. .....3. FEE........................
�i��1u; '� r� uat�trttrtua�t erntit
Permission is reb granted _ _...:..._._........................ .
Yg
to Construc p or�Repair Individu rage Disposx-fi
atNo. `� lL'd.4zZ------ --- ---------------.-•----�" t: �`� ----------•- :.:... _.........
Street
as shown on the application for Disposal Works Construction Permit N ............. Dated ..................
......................................................
i? Board of Health
DATE ---------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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1
3 GALLERY PLACE
OSTERVILLE
A =
Y
4 '
r
DATE:12/4/99 ----
PROPERTY ADDRESS:V2-_Gallery_Place_______
Osterv_ille.Mass_______
02655
------------------------
On the above date, I Inspected the septic system at the above address.
This system consists of the following:
1 . 1-1000 gallon septic tank.
2 . 1-Distribution box.
3 . 2-500 gallon leaching chambers .
Based on my Inspection, I certify the following conditions:
4 . This is a title five septic system.
5. The septic system is in -proper working order
at the present time . r
6. Pumped septic tank at time of inspection .
Maint : purpoeses only . Heavy scum and solids layers .
SIGNATURE:A
Aye
N a m e:_,L L,-Aos4aktr-- L ------
Company: Jose h P Macomber_& Son, Inc . 100
Address: Box 66
CentervilleL Ma_ 02632-0066 (r �o�y��
Phone: 508-775-3338 '
a, •
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachflelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066 `
775.3338 775.6412
4
I COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:3 Gallery Place Name of owner Arnold Lowe
O s t e r v i 11 e M a s g Q 5 Address of owner:
Date of Inspection:' 1 2,b
Name of Inspector:(Please Print) Joseph P.Macomber J r .
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
company Name: J.P.Macomber & Son Inc .
Mailing Address: BOX 66 ('entervi11a ,Mass 02632
Telephone Number: :5 C)8 775
CERTIFICATION STATEMENT
I certify that I have personally Inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The Inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails Inspectors Signature: VA&wzx Dots: =!g _j?
The System Inspecto all submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this Inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the irupet:tor and the system owner
sball submit the report to the appropriate regional office of the Department ofM:nvkotimersW Protection. The original should'be,sent 1ovw
system owner and copies sent to the buyer,if applicable, and the approving authority. .
NOTES AND COMMENTS
revised 9/2/98 Page Iof11
��Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(condmed)
PropertyAddress: 3 Gallery Place Osterville ,Mass .
Owner: Arnold Lowe
Date of Inspection: 12/6/9 9
INSPECTION SUMMARY: Check A, B, C, Or A
A. SYSTEM PASSES:
I have not found any Information which Indicates that any of the failure conditions described In 310 CMR 1.6.303 exist. Any failure
criteria not evaluated are Indicated below.
COMMENTS: Inlet cover to the septic tank is under the walkway
of dark-
B. SYSTEM CONDITIONALLY PASSES:
WIZ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon
completion of the replacement or repair,as approved by the Board of Health, will pass.
Indicate yes,no, or not determined(Y, N,or ND). Describe basis of determination In all Instances. If "not determined',explain why not.
The septic tank is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of
Compliance(attached)Indicating that the tank was installed within twenty(20)years prior to the date of the Inspection; or
the septic tank,whether or not metal,Is cracked,structurally unsound,shows substantial Infiltration or exfiltration, or tank
failure Is Imminent. The system will pass Inspection if the existing septic tank Is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of
Health).
broken pipes)are replaced
obstruction is removed
distribution box is levelled or replaced
- The system required pumping-mare than fourtimes a yeardue to broken or obstructed pipe(s). The system-Mhms
inspection If(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
I
revised 9/2/98 Page 2ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 3 Gallery . Place Osterville ,Mass .
Owner: Arnold Lowe
Date of Irupec6on:12/6/99
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
A)b Conditions exist which require further evaluation by the Board of Health in order to determine if the system 13 failing to protect the
public health, safety and the environment.
11 SYSTEM WiLL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH.YdILL.PRQT.ECT THE PUBLIC HEALTH.AND SAFETY ARID THE EINVIBOKMENT-
ALO
Cesspool or privy is within 50 feet-of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
44 The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for 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 13 equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).-
3) AOTHER
AIN
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddrass: 3 Gallery Place Osterville ,Mass .
Owner: Arnold Lowe
Data of Irtspecdon: 12/6/9 9
D. SYSTEM FAILS:
You ust Indicate either"Yes" or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination Is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of•sewage Into faciBtyer-tyatern componerri•dneKo an overloaded orclaggedSilS-orcesapod.
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 distributionve Oovoutlet Invert due to an overloaded or clogged SAS or cesspool.
x �
_ Liquid depth in Aeespee►is less than fi" below invert or available volume is less than 1l2 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy Is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy i"thin a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy Is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
»coliform bacteria,volatile organic-compounds,ammonia nitrogen-and nitrate nitrogen. -
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems In addition to the criteria above:
AJIP The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No,
the system is within 400 feet of a surface drinking water supply
lthe system-is-witWn 200 feetof-e-4ributaryAoesurfaoadfk*{ #�tw-oupply• - -- - _
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system In accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further infognation.
revised 9/2/98 Page 4of11
I
i
t
j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PropertyAddrew: 3 Gallery Place Osterville ,Mass .
Owner: Arnold Lowe
Date of Inspectional 2/6/9 9
Check if the following have been done:You must Indicate either "Yes" or"No" as to each of the following:
Yes No ,
Pumping information was provided by the owner,occupant,or Board of Health.
None of the system sornpoawas hamwbeen puarpad►f=atJeast two•-weslw aadthe-rystsm h"A"aaeceiaiagwsmal.flow
rates during that period. Large volumes of water have not been introduced Into the system recently or as part of this
Inspection.
4 _ As built plans have been obtained and examined. Note if they are not available with NIA.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or Industrial waste flow.
Z _ The site was Inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System,have been located on the site.
_ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid,depth of sludge,depth of scum.
The size and location of the Soil Absorption System orrthe site has been determined based on:-
_ Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C Is at issue,approximation of distance Is unacceptable)
[15.302(3)(b))
_ The facility owner.(and.---pant- I'differs frootoxme I warapraWded wlth lnfnrg at ou on+hA j rnpar —f
SubSurface Disposal Systems.
i
t
f
revised 9/2/98 Page Sof11
1 ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
P,opertyAd&,,U:3 Gallery Palce 0s•terville ,Mass .
owner: Arnold Lowe
Daft of Inppecton-1 2/6/9 9
FLOW CONDITIONS
RESIDENTIAL• .
Design flow:, /40_g.p.d./bodr9prn.
Number of bedrooms desi )• Number of bedrooms(actu801
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):
Laundry(separate system) s orQ_: If yes, separatelnspection,required
Laundry system inspected ye or no)
Seasonal use(yes or no):
Water meter readings,if available(last two year's usage(gpd):LL1O A Xn ,PCs AVZ* 4,1111i/ .
Sump Pump(yes or no):-A Q
Last date of occupancy:! / J'he
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: AJ uad ( Based on 16.203)
Basis of design flow
Grease trap present:(yes or no)
Industrial Waste Holding Tank present:(yes or no)N
Non-sanitary waste discharged to the Title 6 system:(yes or now:11
Water meter readings,if available: 41V
Last date of occupancy:��
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: ,
System pumped as part of inspection: (yes or no)
If yes, volume pumped: -J�rgallons
Reason for pumping:,9r/Y 1 �e M*jVlor
TYPE STEM
OF
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)
IIA Technology etc.Attach copy of up to dato�operation and maintenance contract
Tight Tank Copy of DEP Approval
Other44
APPROXIMATE AGE of all components, date Installed4if known)-and Sours*ofJnformation:
Sewage odors detected when,arriving at the site: (yes or no)
revised 9/2/98 Page 6of11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:3 Gallery Place Osterville ,Mass .
Owrw: Arnold Lowe
Date of Inspection: 12/6/9 9
BUILDING SEWER:
(Locate on site plan) /
Depth below grade:�
Material of construction:/cast Iron/40 PVC_other(explain)
Distance from Drivate water supply well or suction line
Diameter yIf
Comments:(condition of joints, venting,evidence of leakage,-etc.) ' - "-
Joints appear tight No evidence of 1pakagP
SEPTIC TANK:
(locate on site plan)
y
Depth below grade:
Material of construction:�oncreteAmetal,&Fiberglassitd&Polyethylene4gother(explain)
Aho
If tank is metal,list ageVA 1s.age.confirmed by Certificate of Compliance (Yes/No)
L�
Dimensions:
�r u r i�
Sludge depth:
Distance from top of sludge to bottom of outlet tee ortaffie:
Scum thickness:_
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bo m of ou at tee or baffle:V
How dimensions were determined:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or-baffles,depth of liquid level in relation to outlet Invert, structural-integrity,
evidence of leakage,etc.) ' PUmp the RPntlr tank PVprj& 9-1 Wparc Tn1pi- P. nil tlot
17eac aro n nl ar'P Tha tank i c et riirtiiral l �r �niinrl r Tarn4 c}rn..rc nn
GREASE TRAP:
(locate on site plan)
Depth below grade:,
Material of construction;owconcrete�..OmetaP!kFiberglas3h0 PolyethyleneVother(explain)
Aw
Dimensions: 10
Scum thickness: "
Distance from top of scum to top of outlet tee or baffler �/�
Distance from bottom of scum to bottom of outlet tee or baffle:-AY-
Date of last pumping:�A
Comments:
(recommendation for pumping,condition of Inlet and outlet tees or baffles, depth of liquid level in relation to outlet Invert, structural Integrity,
evidence of leakage, etc.)
Grease trap is not present
revised 9/2/98 Page 7ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 Gallery Place Osterville ,Mass .
Owe: Arnold Lowe
Date of Inspection:12/6/9 9
TIGHT OR HOLDING TANK:_Abf&(Tank must be pumped prior to, or at time of, Inspection)
(locate on site plan)
Depth below grade:
Material of cons truction:concrete41#nstal4!&iberglasatLiOPolyethylenqA&!other(explaln)
R - ---- -
Dimensions: AJA
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm In working order:Yes/4g NoA0
Date of previous pumping: M_
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
Tight or holding tanks nre agt—present
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:�
Comments:
(note•if level and distribution Is equal, evidenoe of solids carryover,evidence of leakage Into or out of box, etc.) — -—
Distribution box has nnP lnteral .No evldeeee 6� solids—�y -e r
No Pvir(Pnre of i ®akage je#e ege-ut—ear
PUMP CHAMBER:¢'
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
Pump chamber is not =rPePnt
revised 9/2/98 Page 8of11
E
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 Gallery Place Osterville ,Mass .
Owner: Arnold Lowe
Date of Inspection:12/6/9 9
SOIL ABSORPTION SYSTEM(SAS)Z
(locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits,number:
leaching chambers,number:
teaching galleries,number: A)V
leaching trenches,number,length: Ao
leaching fields, number, dimension
overflow cesspool,number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
Loamy sand to medium honey dand - No eigne of hgrirniil ; r fa; l „rc
or i nndi n$ Cnjj c arc dry Vaset;atj@H jS Reis1l}al
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: 141W _
Depth of solids layer:
Depth of scum layer:
DimenslOtlf of cesspool:
Materials of construction: AX
Indication of groundwater:
Inflow(cesspool must be pumped as part of Inspection)
Cesspools are not present .
Comments:
III (note condition of soil, signs of hydraulic failure,.level of pending,zondition of.vegetation, etc.)
Cesspools are not present_
PRIVY:A�wQi
(locate on site plan) �1
Materjais of construction: / ff Dimensions:
Depth of solids:_A�L
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.)
Privy is not present .
i
revised 9/2/98 Page 9of11
a
SUSSURfACE SEWAGE DtSPO$AL SYSTTJA WSPECTION FORM
PART C
SYSTEM WFOR3, noN(candrK+e4)
3 Gallei y Place 0sterville ,Mass .
Arnold Lowe ,
D.2. or 4sp.cd«,: 12/6/9 9
Su7CH OF SEWAGE DISPOSAL SYSTEM:
Include des to it I►►st two permensnt reference landmarks or benchmarks
lows ►II wells wlWn 100' (Locets where pubUo water supply comes Into house)
•
4 •
u01j3tulsu0D:paptnoid 'G dap r
c^
i puB S apU pm Aldmoo i
e otp ui poquosap se pug
Igpa110301 MOISAS nevi ed 9/2/98 rap 10of11
mA Agaiaq st.uotssimaad
I lend A .
-ON
L2 9-
b
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddress: 3 Gallery Place Osterville ,Mass .
owner: Arnold Lowe
Data of kupection: 1 2/6/9 9
NRCS Report name
Soll Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Collar
Shallow wells
Estimated Depth to Groundwater_4Feet
Please Indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
bserved.Site(Abutting propert observation hole, basement sump etc.)
_LZDetermined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators,Installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used Water Tables Map .
Gahrety & Miller Model
12/16/94
revised 9/2/98 page llorIll
.% 9
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TOWN OF Barnstable BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION I
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-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 3 Gallery Place Osterville ,Mass .
F ASSESSORS MAP , BLOCK AND PARCEL # Z/ 7
OWNER' s NAME Arnold Lowe
rrr�
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr .
COMPANY NAME J. P.Macomber & 94rt Inc .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508 ) 775- 3338 FAX ( 508 790 _ 1578
A
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 .
Check one ;
r
System PASSED _
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or' the environment as defined in 310 CMR 15 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have con cted has found that the system fails to
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
1" 1 " z
Inspector Signature t Date
Dn6copy of this certification must beprovided to the OWNER, the BUYER
where applicable ) and the 130ARD OF HEALTH.
* If the inspection FAILED, the owner or".operator shall u d
within o*ne year of the date ' of the inspection, unless allowed ort required
he m
otherwise as provided in 3.10 CMR 16 . 305 .
partd .doc
« r
r L ., ION SEWAGE PERMIT NO.
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INSTA LLLR'S MAME & ADDRESS
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8UILDER// Olt--'.OWN EN
DATE PERMIT ISSUED 3 ��
DATE COMPLIANCE ISSUED' Z gS
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THE COM/MHONNWEALTH�OFUMASSACHUUSETTS
' Jam.��B�®/"'C IZ® i— �1 E 1
...------/ 41!5. "O ....---.OF...-----
Appliration for Disposal Works Tunstrnrtiun rnmit
Application i hereb made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: Vf:
... `1`� IdIA40a------.....( .---••---------•....................... ---•----------.....---------.....-------•
-
Coca n-Address or Lot No.
7
Owner - -••-•--••----•Address
Installer Address
d e of Building Size Lot............................Sq. feet
V Dwelling: o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type
of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ------------------------------------------------------•-•-----------•--•••--••----------•----------------------•-----•---------------•-••------------
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
9 Septic
id
Disposal Trench Jiq Nocapacity_..--:._ gallons LengthTotal Length Width........-----_'Tootal leaching area_-Depth-_---..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------_.................
ri Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a • -•------------------ -------------------------•------•----------••-•---•------•-•-----------------•••-•--------------------•-•--••--------•••-----------
0 Description of Soil........... ---------------------------------------------------------------------------------------------------------------------------------------
W
U
---------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable..... =_ _� � .___.•_________________________________
----------------------------• .. ......................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Co pliance has been i ued by the oa of h th.
Signed --- -----_-- �� �
Application Approved By_____________ ______ .....
S Date
Date
Application Disapproved for the of owing reasons-------------------------------------•---------•-------•-------....--------------•--•----------•---.....__..._.
..............•.....................................................................................t....................................................................................•...............
Date
PermitNo.........................................:.............- ` Issued_.......................................................
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M AC'L
DATA
i
No......................._ Fps.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEAL-fTH
x' f i .........O F:.....................: i,:�11
s ........ ..................................
Appliratiurt for Disposal Works Tonstrurtion ramit
Application is hereb made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: %
a.
J / Location-Address or Lot No.
;-
-----•-•----- •--------•----- •-
Owner Address
a .. q
Installer Address
d itype of Building Size
Size Lot............................Sq. feet
U D wellin �'N . of Bedrooms:...........................................Ex anion Attic 1--+ g p ( ) Garbage Grinder
a ...:_.....
Other—Type of Building ................... No. of persons............................ Showers ( ) — Cafeteria ( )
� 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..........................
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.........-.......... Depth to ground water........................
Description of Soil.. =%WL-8_ 44'4 �-1-------------------•---------•--------......-------------------------------------------............................................
x
c.> --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-----
w
air a�'
U Nature of Repairs or Alterations—Answer when applicable..._.
t
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Co pliance has been issued by the.-board of health. f
Signed., _ ___>4 <
r.
V ...........................
`------•-•------ ... j�-------•------ .Date-
Application Approved BY----•--••-=--- � -QAAA- .. TS
Date
Application Disapproved for the' of owing reasons-----------------------------------------------------------------------------------------------------------••--
,tyi � tirt `r Date
PermitNo.....'..........= ..................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O`jF HEALTH
.. ........ .. ...... .....:... .........................................................
Tirtifirate of Tompliattrr
T„UIS pS TO�CFRTIFY, That�the Individual, Sewage Dispos,�l.System constructed ( ) or Repaired
by.._—!rc. ......
......---
-
-
Installer 1-7
,
w
has been installed in accordance.rwith the provisions of TITLE . 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No........ ___S S__ --- ------------ dated_-------5-----�.:�-g�-............
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® S GUARA TEE THAT THE
ySYSTEM WILL FL4NCTIQN SATISFACTORY.
DATE...............�p. ...... ......... ... Inspector...............2
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEALTH
FEE `..�.__......---
�i��ruu�tl ur�;� �u�t�#rtiu�t min
Permission is hereby granted..::'`........................° - =_`:1 fr ft rs........ � ...
_.....
to Construct ( ) x Repair / --"an Ind)v}dual Sewage Disposal System
atNO.._' i '''° ✓ ��' � ; t ...............� ''.,� ... .. �. i "a..z�r- . ...................................................
Street
as shown on the application for`1-1 Disposal Works Construction Permit No.'- V 3 Dated......57n.?... ..:.._�...
.......................................... --------•--
2 B d of ea1tH�"
DATE---------- `..3.0-- ...............................
FORM 1255 A. M. SULKIN, INC., BOSTON y` -