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HomeMy WebLinkAbout1045 MAIN STREET (OST.) - Health ,1045 Main Street (Ost:) 4 =r Y11 009 , ' ° .. rt No4?, Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for b1spopal ftstem Onstruction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( UCompleteSystem ❑Individual Components Location Address or Lot No./f)CjS' �yl />° O ner's Name Mdress,and Tel.No. Assessor's Map/Parcel Installer's Name Adajpss,and Tel.No.tS 2O"(7'7-;X_ Designer's Name,Address,and Tel.No. ./05�j�h j oj4Pea-) D�� d?'/s�r fates i Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow,(min.required) ADO, gpd Design flow provided fir• gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) $"r'!��/ Fy4f 10/°pL 6,el y, 60ro,71l 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 this Board of Health. SS1 - ed _- Date Application Approv Date Application Disapproved bV1 Date for the following reasons Permit No. Date Issued 71E1/j� No. � ^0t� 1 �`�- Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I' Yes .PUBLIC HEALTH DIVISION —TOWN OF BARNSTABLE, MASSACHUSETTS ftpfication for Misposal fpstem Conlruttion Permit r'c Tiavl, Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon,( ) ❑Complete System Individual Components Location Address or Lot No./Q yS � T Owner's Name,Address and Tel.No. Assessor'sMap/Parcel i .-�-'QS /eli;4,rd 0/ CF -Ai h/^r-115 _ flnstalier's Name,Addressrand Tel.No.sa6 y0U-V 7,j X Designer's Name,Address;and Tel.No. Jos-eph C]e 0,4rr�a-) j 07 C 4";-7,'7-e Tl` 9W 0&rs fa`l_S Type of Building: x> �ti. . Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons ` �. Showers( ) Cafeteria( ) Other Fixtures 'Design Flow(min.required) AA gpd Design flow provided gpd i Plan Date Number of sheets Revision Date Title t f Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ZO // /'PVC /-1,p/. 1' aw 60", 9 S�7"4 etc/�Ti�U S,c-YpTi� Trek all7fi Date last inspected: Y Agreement: t The uridersigned 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 this Board of Health. / /Signed / - �l Date �2_/1�J1 Application Approved by L� /Ij ' � t, Date �~Application Disapproved b �y Date) for the following reasons Permit No. 20 i A % n 6 19 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS 'Certificate of Conmpfiante THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) i Abandoned( )by5/'� �/ / at- _ has been constructed in.accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.701 E-0647 dated 3121 Zola Installer 1MWf 4D Designer #bedrooms r� ` 0 Approved design flow NA gpd The issuance of this permit shall not breco/nst2rued as a guarantee that the system will function as``designed. t "7/ ! Inspector y Date - - - ---- --= - -- - -- ------•------------- ----- ------------- ----- ---------------------------- _------ ------------•--- No- A i 1) - 061 Fee 9 em. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 33isposal 6pstem ConstrUttion 3permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at 4 and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 this permit. Date Z / �(�/ Approved by (` TOWN OF BARNSTABLE LOCATION /DyS Moll n St SEWAGE# 2•a ly - 30 `= VILLAGE 0SiC r yi)1 C_ ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. B 4 Q EX Ca►Vo,4%'O^ q 77 -OG 53 SEPTIC TANK CAPACITY 2 O X R-_P6Cc_rrlcrti OrJL Y LEACHING FACILITY: (type) (size) NO. OF BEDROOMS OWNER T l,n oaa 1a►,no4_ PERMIT DATE: $• Z S- /y COMPLIANCE DATE: $• 2,9 - )q 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 Al ' 1s+� AZ A3- �3 4 B3- Z3 A fly - + 2 y No. t H Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS application for ]Disposal 6pstem Construction Permit d-bob Application for a Permit to Construct( ) Repair( ) Upgrade( )' Abandon( ) ❑Complete System Individual Components Location Address or Lot No. /o� 146, -AA atn 51- Owner's Name, ddress,and Tel.No. Assessor's Map/Parcel W f rev l 1 '� &q J"h n r/`0Oq I a1 0 �b /7, 28 i -Sf 23 Installer's Name,Address,and Tel.No. Designer's N e,Address,and Tel.No. -��;Q �xcav rvn 50�-���-�6s3 cJll TA Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 4 4- Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Ala —b�Y 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 this Boar ealth. Signed IV9PJ Q J& Date Application Approved by Date - Application Disapproved by Date for the following reasons Permit No. — .L�1,: Date Issued - --------------------------------------------------------------------...,.----- ----------------------------------- .-..._ fl 1! fi i ' a`�J_� .•rya%Ga � if � ' No. / / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ' �pYication for Disposal *pstrm Cons tructioi verrnit Jr cl by Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 10145 Owner's Name,Address,and Tel,No. Assessor's Map/Parcel 4 (�5 tiiill-� �� � i J hn Name,Address, t% /7) z .i -sk23 .- '° Installer's Name,Address,and Tel.No. Designer's Na e;Address,and Tel.No. ` Q �xcc�va�r�n 5�A �.7�-a�s3 t-�t1 �� �`. Type of Building: n/ Dwelling No.of Bedrooms /" Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) .ff ' Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of.Septic Tank Type of S.A.S. Deseription of Soil if ..,�;r Nature of Repairs or Alterations(Answer when applicable) } ha o 4 )b O Date last inspected: 'r 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 this Boaz o ealth. Signed Date < 114 Application Approved by Date 5 -1 �- Application Disapproved by Date for the following reasons Permit No. o — 6 Date Issued a g THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance 1` THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by 9((Qv aft 6n fat o 5: Q i n !S+ 06f u v 1 I l-f has been constructed in accordance C with the pr ns of Title 5 and t for Disposal System Construction Permit NoCP 6!(4'36-7 dated Installer t Designer #bedrooms Approved design flow gpd The issuance of this permit shall not b-e-�con trued as a guarantee that the system will function'`as d�es�gned.' Date � <� � Inspector __ �,�i; !`�-- ---�-- - _ -- -- - - - --- --------------------------------------------- ------------ No. :.d1 L 3o-�7- _ Fee 'V V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction permit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at I b y and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 this permi Date lj— {� Approved by Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1045 Main St. Property Address Jonh & Robin Hoagland Owner Owner's Name information is Osterville 'Ma 02655 8-21-14 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms the computer, r, use 1. Inspector: only the tab key to move your Matthew F. Gilfoy cursor-do not Name of Inspector use the return key. B&B Excavation Company Name VQ 14 Teaberry Lane . Company Address N t� Sandwich Ma. $ 02644= ICI City/Town State Zip Code;. (508)477-0653 S113640 $� _ Telephone Number License Number B. Certification y �� certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310:CMR 15.000). The system: ,® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-21-14 Inspect 's Signatur47 Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of.Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 'Lob I t5ins•3/13 Title 5 Official(jetion Form:Subsurface sewage isposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form { s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.' 1045 Main St. Property Address Jonh & Robin Hoagland Owner Owner's Name information is required for Osteryille Ma. 02655 8-21-14 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box.for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or.not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. - *A.metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. El Y ❑ N ❑ :ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1045 Main St. Property Address Jonh & Robin Hoagland Owner Owner's Name information is required for Osterville Ma. 02655 8-21-14 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): El 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): El broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): . ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health', safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water. ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1045 Main St. Property Address Jonh & Robin Hoagland Owner Owner's Name information is required for Osterville Ma. 02655 8-21-14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system,has a septic tank and.SAS and the SAS is.less than:100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or,cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1045 Main St. _ Property Address Jonh & Robin Hoagland Owner Owner's Name information is required for Osterville Ma. 02655 8-21-14 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOTdue to clogged or ❑ ® obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ M 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 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 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply El ❑ the system is within 200 feet of.a tributary to a surface drinking water supply El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1045 Main St. Property Address Jonh & Robin Hoagland Owner Owner's Name information is required for Cisterville Ma. 02655 8-21-14 every page. Cityrrown - State Zip Code Date of Inspection C. Checklist Check if the following have been done. You.must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ Z 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? El ® Was the facility owner(and occupants if,different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System. Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 44.10 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17. Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,. 1045 Main St. Property Address Jonh & Robin Hoagland Owner Owner's Name information is required for Osterville Ma. 02655 8-21-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (god)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 31.0 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1045 Main St. Property Address Jonh & Robin Hoagland Owner Owner's Name Osterville Ma. 02655 8-21-14 information is required for, every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/user Date Other(describe below): General Information 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: Type of System: ® Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ .Privy ❑ Shared system (yes or noj (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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1045 Main St. Property Address Jonh & Robin Hoagland Owner Owner's.Name information is required for Osterville Ma. 02655 8-21-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known) and source of information:. 1987 - Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1,8„ Depth below grade: feet Material of construction: ® cast iron Z 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank (locate on site plan): 17' Depth below grader feet Material of construction: ® concrete ❑metal. ❑ fiberglass - ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by.a Certificate of Compliance? (attach a copy of certificate) ❑ Yes 0 No Dimensions: 1500 gal. 3" Sludge depth: l5ins-M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1045 Main St. - Property Address Jonh & Robin Hoagland Owner Owner's Name information is Osterville Ma. 02655 8-21-14 required for ' every page. CitylTown State Zip Code Date of Inspection D. System Information (cost.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33-1 0" Scum thickness Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS How were dimensions determined? measured ' Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order;Tees present no sign of back- up.Liquid level equal with outlet invert. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1045 Main St. Property Address Jonh & Robin Hoagland Owner. Owner's Name information is required for Cisterville Ma. 02655 8-21-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight r I g t o 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 . 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 5. 1045 Main St. Property Address Jonh & Robin Hoagland Owner Owner's Name information is required for Osterville Ma. 02655 8-21-14 , every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 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.): New D-box was installed that is level and has riser present. 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official inspectionForm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1045 Main St: Property Address Jonh & Robin Hoagland Owner Owner's Name information is required for Osterville Ma. 02655 8-21-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 5 (4'X4') ❑ leaching trenches number, length: ❑ leaching fields 'number, dimensions: ❑ overflow cesspool number: ❑ Innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of:ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appears to in working order no sign of hydraulic failure. Galleries had 8" water at time of inspection. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY y` e 1045 Main St. Property Address Jonh & Robin Hoagland . Owner Owner's Name information is required for Osterville Ma. 02655 8-21-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,, etc.). Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 t _ Commonwealth &Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1045 Main St. _ Property Address Jonh & Robin Hoagland Owner Owner's Name information is required for Osterville Ma. 02655 8-21-14 every page. CityTTown State Zip Code Date of Inspection D. System. Information (Pont.) 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 thearea below' 0 drawing attached separately - q 0 o I a o , A-3 -. �3' 1?53 23' i A y 2 - y 3' t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1045 Main St. Property Address Jonh & Robin Hoagland Owner Owner's Name information is Osterville Ma. 02655 8-21-14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >10 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 87 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: Plan on file at boh: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1045 Main St. Property Address Jonh & Robin Hoagland Owner Owner's Name information is required for Osterville Ma. 02655 8-21-14 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Qd COMMONWEALTH OF MASSACHUSETTS 3� oS A�' ' , EXECUTIVE OFFICE OF ENVIRONMENTAI'C) ` OF' 'AF .�i DEPARTMENT OF ENVIRONMEFOARFIjiOjrgCfT1AN DIVISION TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1045 Main Street Osterville.MA 02655 rAR Owner's Name: Karen&John Butler PARCEL Owner's Address: La Date of Inspection: March 11, 2005 Name of Inspector:(Please Print) James M. Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 OsterviUe.MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported. below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector-pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs F her Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: March 13, 2005 The system inspector shall sub i a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector.and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1045 Main Street Osterville: MA Owner: Karen&John Butler Date of Inspection: March 11,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with.. approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1045 Main Street Osterville, MA Owner: Karen&John Butler Date of Inspection: March 11, 2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR'15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner thatprotects the public health,safety and environment: t 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1045 Main Street Osterville, MA Owner: Karen&John Butler. Date of Inspection: March 11, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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 ✓ 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the p y 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.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: , (The following criteria apply to large systems in addition to the criteria above) Yes No _ 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 1.5.304. The system owner should contact the appropriate regional office of the Department. . 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1045 Main Street Osterville, MA Owner: Karen&John Butler Date of Inspection: March 11,2005 Check if the following have been done: You must indicate"yes"or"no"as to each of the following- 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 riot 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? R The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ' ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined.in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 r Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .,SYSTEM INFORMATION Property Address: 1045 Main Street Osterville, MA Owner: Karen&John Butler Date of Inspection: March 11, 2005 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 5 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system;(yes.or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Punned 2 years ago-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 6130188-ver as built card Were sewage odors detected when arriving at the site(yes or no): No 6 l ' Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYS TEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1045 Main Street Osterville, MA Owner: Karen&John Butler Date of Inspection: March 11, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 5" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels . as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage GREASE TRAP: None (locate on site plan) Depth below grade: 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: 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 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1045 Main Street Osterville, MA Owner: Karen&John Butler Date of Inspection: March 11, 2005_ TIGHT or HOLDING TANK: None (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/da Y Alarm present(yes or no): Alarm level: Alarm in working order(yes or no):. Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. PUMP CHAMBER: None (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.): 8 Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION(continued) Property Address: 1045 Main Street Osterville,MA Owner: Karen&John Butler Date of Inspection: March 11, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not-required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: ✓ leaching galleries,number: 5 leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The Qalleys had 1.5'ofliauid on the bottom. The scum line was at the same level There did not appear to be any s_ igns of allure CESSPOOLS: None (cesspool must be'pumped as.part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 f Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1045 Main Street Osterville, MA Owner: Karen&John Butler Date of Inspection: March 11, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. p a 3 13 A3 O3 o y y a8 y3 a 10 ' Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) s Property Address: 1045 Main Street Osterville. MA Owner: Karen&John Butler Date of Inspection: March 11, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 15 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours taps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours tans the[naps were showing�at7proxittzately 15'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection.This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTickct,Ma. (508)564-6813 TRUDY COXE Secretary - ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION 9 !� Property Address: . 1045 MAIN ST. OSTERVILLE MAP 118 LOT A N �♦ Name of Owner MR.BUTLER Address of Owner: SAME 'AYE Date of Inspection: 2/22/99 `` 3 1999 Name of Inspector:(Please Print)JOHN GRACI to I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) YCN+w&ft Company Name: John Graci Title V Septic Inspection 4* Mailing Address: P.O.Box 2119 TeaTicket,Ma.02636 Telephone Number: (508)664-6813 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The Inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The Inpection is based on criteria defined in Title V _ Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is _ Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:2/23/99 The System Inspector shall ubmit 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 inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1045 MAIN ST.OSTERVILLE MAP 118 LOT A Owner: MR.BUTLER Date of Inspection:2122/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. NO 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. NQ 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 pipe(s)are replaced obstruction is removed distribution box is levelled or replaced NO 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 i revised 9/2/98 Page 2 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1045 MAIN ST.OSTERVILLE MAP 118 LOT A Owner: MR.BUTLER Date of Inspection:2122199 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of 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. _ 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 is equal to or less than 5 ppm,Method used to determine distance 11La_(approximation not valid). 3) OTHER t� revised 9/2198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1045 MAIN ST.OSTERVILLE MAP 118 LOT A Owner: MR.BUTLER Date of Inspection:2122/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nta. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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 ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,Is in Hydraulic Failure. 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: 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system Is located Ina 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 15.30412).Please consult the local regional office of the Department for further information. II . revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1045 MAIN ST.OSTERVILLE MAP 118 LOT A Owner: MR.BUTLER Date of Inspection:2122/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system 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. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X 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 on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 11 5.302(3)(b)J X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1045 MAIN ST.OSTERVILLE MAP 118 LOT A Owner: MR.BUTLER Date of Inspection:2/22199 FLOW CONDITIONS RESIDENTIAL: Design flow:AM g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual):4 Total DESIGN flow: 440. Number of current residents:4 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no).M Seasonal use(yes or no):JLQ Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NO Last date of occupancy: nLa COMMERCIAL/INDUSTRIAL Type of establishment: nla Design flow: nla gpd(Based on 15.203) Basis of design flow: n/a Grease trap present:(yes or no):JIO Industrial Waste Holding Tank present:(yes or no): XG Non-sanitary waste discharged to the Title 5 system:(yes or no):DLO Water meter readings.if available:n& Last date of occupancy: nLa OTHER: (Describe) nLa Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):MQ If yes,volume pumped nLa- gallons _ Reason for pumping: nla TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: SYSTEM WAS INSTALLED IN 1988 PERMIT COMPLIANCE ON 6-30.88 Sewage odors detected when arriving at the site:(yes or no): MQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 MAIN ST.OSTERVILLE MAP 118 LOT A Owner: MR.BUTLER Date of Inspection:2/22/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 1'6" Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: n& Comments: (condition of joints,venting,evidence of leakage,etc.) n(a SEPTIC TANK: X (locate on site plan) Depth below grade: V Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nla If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MO Iva Dimensions: 1 8'6"H 6'7"W 4'10" Sludge depth: Z Distance from top of sludge to bottom of outlet tee or baffle: 2 Scum thickness: Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 16_' How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM FOR MAINTENANCE EVERY TWO YEARS, GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) n/a Dimensions: n& Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:JI& Distance from bottom of scum to bottom of outlet tee or baffle n(H Date of last pumping: n(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.) nta revised 9/2198 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 MAIN ST.OSTERVILLE MAP 118 LOT A Owner: MR.BUTLER Date of Inspection:2/22/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: WA Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) IVA Dimensions: nla Capacity: n& gallons Design Bow: n/a gallons/day Alarm present: NQ Alarm level:jiLa- Alarm in working order:Yes—No—: NQ Date of previous pumping: Wa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Wa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:nla Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) nLa PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 MAIN ST.OSTERVILLE MAP 118 LOT A Owner: MR.BUTLER Date of Inspection:2/22199 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nLa Type: leaching pits,number: n& leaching chambers,number: _nLa leaching galleries,number: &GALLERIES leaching trenches,number,length: nLa leaching fields,number,dimensions: nLa overflow cesspool,number: n& Alternative system: nla Name of Technology: j)La Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE GALLERIES ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY THE WAS 1'6"OF WATER IN THEM AND NEVER ANY MORE CESSPOOLS: _ (locate on site plan) Number and configuration: nta Depth-top of liquid to inlet invert: nLa Depth of solids layer: Wa Depth of scum layer. nLa Dimensions of cesspool: n& Materials of construction: Wa Indication of groundwater: nLa inflow(cesspool must be pumped as part of inspection)Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:n& Depth of solids: nla Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n& revised 9/2/96 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 MAIN ST.OSTERVILLE MAP 118 LOT A Owner: MR.BUTLER Date of Inspection:2122199 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a D to Is AQ �� AC a� LB revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1046 MAIN ST.OSTERVILLE MAP 118 LOT A Owner: MR.BUTLER Date of Inspection:2/22/99 NRCS Report name: nla Soil Type: nla Typical depth to groundwater: n1a USGS Date website visited: nIa Observation Wells checked: MQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers XUsed USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS AND VISUAL revised 9/2/98 Page 11 of 11 -Ally- TOWN OF BARNSTABLE L0, ATION y /V1A 1/� SEWAGE # VI LAGE d Mrv' ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) G/4 1 S (size) NO.OF BEDROOMS —�—� BUILDER OR OWNER L) J PERMTTDATE: . COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility .Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leachi'g facility) -' Feet Furnished by .L/1 rjQ e til m J - �Ot� r � is is 19 O a - 3 13 Al p 3 y Lgg y3 o y ASS S_S:OR'S MAR- NO. 411 PARCEL C#� !. r�C``A' �16N S E W A C E PERMIT NO. zos/r ^mw g2K�� VI'LLAC E - INSTALLER'S NAME A ADDRESS KT VZAJ h/cK€f B U I L D E R OR OWN ER �7/r`c G2Q��C�rL DATE PERMIT ISSUED �_� `��8� PAT E GOMPLI.ANCE ISSUED 0/, 't_ r _ _ _ _ 1 3 t l ,� � 1� �b �,� No..-•,9-7...ZTir Fes$... ............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH s TOWN. ............._.....OF......BA.i? STALL.B----------------------_.........•••••.........•--- Appliration for Uiipngal Mirkii Tnntrnrtinn Urrmit Application is hereby made for a Permit-to Construct ( ),or Repair (X an Individual Sewage Disposal System at: 1045 Main S t . .................... -- Location-Address or Lot No. .... ALYCRO.- ............................................... .......P....O.__.BIIX...7.7.5...IIstar.vd-l1z......M-............. Owner Address W Installer Address Type of Building Size Lot-.3-9,1aa---------Sq. feet U Dwelling—No. of Bedrooms............ ..............................Expansion Attic ( ) Garbage Grinder ( ) PLOOther—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures ---------------------------------- Design Flow............. ........................gallons per person per day. Total daily flow............................................gallons. RW'. Septic Tank—Liquid capacity 1500gallons Length.....1.1...... Width........!...... Diameter---------------- Depth.....6.�_-lot - Disposal Trench—No. _.A............. Width....... ........... Total Length......2 Q.._...... Total leaching area....2.9 2_...-__.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...�iChae J........Donovan Date......10/13./_8.7........... 1 Test Pit No. l................minutes per inch Depth of Test Pit..... ....... Depth to ground water.......n l_a_------:. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-.----_.._..---.-..---- •-••-------- -------------•••--•••........----•...---..............•--•-------•-----........--•-•-----.....•----••--.....---•------•-----•---...-----•--•-- O Description of Soil.................1 . 5± tQp,,AJ.§ubsoili• 1.5-bothole medium- coarse-_•sand_--_.. x U .....................................•----•--•--•-----•-•-....-•-----•..............••••--••----•••----------------------•-•-•-•----•-•-•----•-•-----•---•-------••--•--------------•----------•-------- x ------------------ - ------------------------•---------•--------••---•--------------•---•---••-•------•-•-•-----•--•---•-•-•--------•--------------------••--------••------•-•-----•--••----•---..... - U Nature of Repairs or Alterations—Answer when applicable_.'I'o---- &Ung...cess-p-o-o1-.............. Agreement: . The undersigned agrees to install the aforedescribed Individual Sewage Disposal�System in accordance with . the provisions of'TTL y g g p y 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in C operation until a Certificate of Compliance has been issued by the board of health. tSigned................................ ................................................... ............--•-............... `^ Date e Application Approved By.............01� .................................... ...........&!%_/-�-mff?----- Date Application Disapproved for the following reasons:.-------- ......................................... ........................................................... ..............••-•-••-•......---•-----•-•-• .........------•---••......---------- ......•-----••--...-••--.......--•-------------•• -•----•-•-•-•--------•---------------------•--•----•----•..._. - Date Permit No........� ?.-..7.s ....`..------..... Issue(L....................................................... Date t 97- 75- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TORN..............................O F........5,AF N.S.TAJ3L.E.._......--•--------•--------•...--••---••........ Appliration for Disposal Works Tonotrnrtion Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ()4.) an Individual Sewage Disposal System at: 1045. Main S.t.:......0 s t e i a i 11 e.,.._MA ....................1.1$=q �A$$e.'.552��)------------------------------ Location-Address or Lot No. ALYCRO .•--'•P.0_: B0X 7.7..5...9s���Y..1.1.].�- - __........... ... .............................................. ... . owner Address W Installer Address QType of Building Size Lot...39,_533•.......Sq. feet U Dwelling—No. of Bedrooms.............. ............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria PaOther fixtures -----------------------------------•-------------- . W Design Flow.....440:..............................gallons.per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity._150qallons ' Length.......1.1.... Width....6......... Diameter................ Depth.6_......1 x Disposal Trench—No...........�.__...... Width........4......... Total Length__---2-0..._...... Total leaching area----..2� ......sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( x) Dosing tank ( ) aPercolation Test Results Performed by......giEha,&J;...j.,-...&Gito-van................. Date_.j.0_.j3_8_.7................ Test Pit No. I.......<-2....minutes per inch Depth of Test Pit......_1_a 1:.__. Depth to ground water...Gfa------------- fs, Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................ •---------------------------------------•--------•..............----•----........_......•--•--._.---......................................................... Description of Soil-•-------_1_5 ...LOP...&..-si�bs-0-i•1--g-•--�-,-5•--�o�i�©�� mc-d i-u-m--�cGar s-e....sand------•----- W -•••---------------•----••--••••-•-•--•••---•---•---•--••--•-------•-----•-•-------•--•-•-••--•-••••--•.....••-•-------------•---------------•••---••------•--------....•••----••--•-------•----....---- U Nature of Repairs or Alterations—Answer when applicable..T-a.-.i:.ep.t-,ace----ei-x-i-&ti-rig---- -essP4©-1•••••-•••••.. ----------------------------------------------------------------------•-------•-----'--••--..............••---•----------------------------------------•---------------------------------•.....----..-•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT!Z- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed..........................140, ----------------------------------------------------- ---•----------------•--------•-- ........ .._ ..7D_at� Application Approved By.......... Date Application Disapproved for the following reason r°_..... --••-•-•••--------------•••-••---••-•--•--•-----....--•---.......---.....--•--•-••... -•.....----....•------•---------•-------------•------•-•-----•-•--••---•-•••.._..---•-•-----• --•.........-•--- Date Permit No..&_7._.....7.5 R... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,/ `t,....................OF....� -�...: e C............................................. Trrtifirate of Tomplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ) by............. ._.... .. �,._.._..... .".+.._------------•--------.----------•-•-•-•-----••-----------------.-•---.--•-.------------ --- -------- � _-----------•- ro �-s h�• j . at...................................................................................................................................................................................................... has been installed in accordance with the provisions of TITfl7 5 oPI&FState Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector..................................................................................... THE COMMONWEALTH OF MASSACHUSETTS r� BOARD QF HEAIpTI/,) U 7-" 75 ............................... ...OF..................................................................................... No......................... FEE........................ Disposal Works Tonotrnrtion rrmit Permission is hereby grant*-------------------------------------------------------------------------------------------------------------------------------------------- to Construcf 45 )yo6ReV1Aro(,,;�). anSIj—hdividua c�i�. ftaspb ystem atNo........................................................................................................--------------?j.-,7S-a`'...................................................... Street as shown on the application for Disposal Works Construction Permit No __________________ Dated.......................................... ` r .............••-••----------- --........ -•••---•----••••••--•-----.....------.................. C � - ,G 6- a Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS av [ 0 �. #1 8 46 , ` �5•�� i Form galley N N - f� l a Icepo 2 \ D �• a 153.40' Q°c PROP. GARAGE r---, 32.79 (ON SLAB) i W S t x 33.2 , 32.87 Locus— Cb �a08� #3 8.54 3 01 --x 32.58 0 X�' \ �o Sou h 33 1 33.43 rn •\ #4 O o �rS3.37 \ r 100.0' y�� r--- 28 v \ =o ` EXIST. SHELL DRIVE\ -- 8 32.73 e5 - 4.0 .i 'o in r/ \ C3 I � 433.81 \ LOCUS MAP � SCALE 1"=2000'f #5 PROPOSED WORK LIMIT LINE / ♦ / � x 33.81 9.01 (SILT FENCE) ♦` i i Z ASSESSORS MAP 118 PARCEL 9-1 34�6-------- 34.38 LOCUS IS WITHIN FEMA FLOOD ZONE B x 34.36 I & C (GARAGE IS IN C) ZONING SUMMARY 9.05 ° ZONING DISTRICT: RC #6 LOT AREA MIN. FRONT SETBACK 20' 26,426f S.F. / h EXIST. DWELL. MIN. SIDE SETBACK 10' / I MIN. REAR SETBACK 10' / SEPTIC SYSTEM AS PER DEP INSPECTION LC REPORT, D. 3/11/05 o 0 241 SITE PLAN 63' / . , I OF .I 1045 MA IN STREET OSTERVILLE off 508-362-4541 $ N OF'kq fox 508 362-9880 y C DANIEL yam PREPARED FOR ` down cape engineering, inc. A. `� PINE HARBOR WOOD PRODUCTS OJ C/VIL ENGINEERS '3'NO.4098014 LAND SURVEYORS <`' PE 0 APRIL 25, 2011 939 Moin Street — YARMOUTHPORT, MASS. N_ZS-ZOO\ rSNDS Scale: 1"= 20' 11-086 DATE DANIEL A. OJALA, P.L.S. 0 10 20 30 40 50 FEET 3 t a , -� PIS ®R WOOD PRODUCTS 111 I S OL ,eIF— ji s I i i 1 I j 777 rN " SCALE: t — APPROVED BY: W / (j � DRAWN BY MT7 . � ( vvl , DATE: REVISED ? DRAWING NUMBER t. r .. . .:.�.e�c�g.�. - _�._t�# �`.E3''L'�. .... ,. •�_,? - � tt �as.g.. - ::: ���.:�_.E-=.yy :..e �}�!L TEST PIT Dt-ETA. JIIANMOLE a'n'ER TO Fi>d:Sli aR.IOEE� f5 f/�° NO. OF OL?LETS: 3 _ Revisiorts: -----� ;', NOTES.' O S T E R V I L L E i I/13/87 NOTE ADDED ' 1-,"MIN. 6„ 1. Dlo'TRIPGTION BOX TO WITHSTAND H•10 F:.AN VIEW ':,'''� INDICATES I C _. INDICATES GBSElk6'ED DER r------� LOADING L'hLESS UNDER PAVEMENT. DRIVES N.T S. . PERC Gtof'kD ATER ! ! _ _ ,' J I OR TP.AVELED WAYS WHEREBY H-10 LOADING FINISH GRADE 2 % MIN. S_i�PE r , TEST �---= - - - - - - - -• - - - 't. ...• .- • '. .•. _ + • •► HALL APPLY. r - - - - - - - - - - - �- t2„ 4 IiiLET N I i IK 1/2� I�uMlN. 4 2„ , AVER Y c� I 1— SLOPE OF 1•ti'L1=T PIPE EXCEEDS OAd FT/fT 2 3/4 -1 !/2 I ' `---TEE 1 I• PROVIDE INLET TEE AS SHOWN WHERC L STO,ti RL r1c TP No. TP No. , - !,-F," �JsECNarctlJ WASHED STONE St• Y '. OR IN .! PUMPED SYSTEM. GRD.EL_ l�;i.2 r GRD_EL. ; — Ps r-U ST,STEEL — ;. C, 3,► I -EJ. FIRST 770 FEET 1 Eti SEC,+v.ti �' ' 3„ i ,INLETS CID_{ �� Q DISTRIBUTION BOX TOBIE LAID LEVEL. T - GW.EL. GW EL. :, _ J Ei>ifOr �.Eo - �_ L O:TTL - !• PLAN VFW I (TY?;I WASHED ( � -3i��' SLJ'TJ� TkaJt 5` JhiLET E7 ^ ., i I 1 LOCUS N SAM POND o 4'-9' TEE 4'-0 m!)c TEE v-I 4. RECOAfAfENDED MANUFACTURER • - 1 t �STdNE \ , � , I LIQUID GEPTM -- ROTONDO OR APPROVED EQUAL .¢ � ��JJ � TOP 8 SUBSOIL 1 I I '/4" F{1<M'JVABLE C>01►E7t I i ' '° WEST i p -� 6 Mt%l.3/4"t0 !-t/2 ST04 • - - - ! 2 --+--- 4 --+{� 4 - -}►- 2 BAY �'� 8A't' ST 2 G+ 5 OtA.OtITLETt3I - - - -, i ! ---- 24' - - - 2 - a �— F 1 T E 4 I I`-_ ----- �. BOTTOM ON LEVEL STABLE BASE �. o � .- r✓ : c�rO.ID_ ( st:cTlGti I CROSS SECTION ., 'a °'+ -► p C �r c t o `r »...- -� f —�— MM J '•. ht 4iT I TYP _ l L--zd"O;A. t�A9tHGi E C_. i R " J04kt75 trfQt i I I 4' III N. TS. 4 INLET Re`erenceS: 4 4 F W i f! I 4"OUTLET _,, PLI+�d V�,4N CROSS SECTION VIE , I-� 71/`` '1 `2. - 5I/2" I I Ex1STING Ci�fh:!'iC�NS 5 MEC.- C OAR�E 5 !y(.;-Es: 1 1 e - - - - i SANG 1 r, cT.0 r,y t• TO µ'::''."� 4 tir^ � 10 LOA:)!,ti'G 3 I h "+• ,�VD OL'.'LET TEES TO BF_ CA.`."?- IRO,'v. c_ � + `- --' INLET 5 6 c 1 ,,_ , F FA3'i�t::, �f c�s L ;t �v£LEL' s �: >a�': �:'R cdST l.ti t .�Cu CO%'�h'TE. �-- . . �Y----SOTTDw Ok ��_____ — j E vY ELDi�JCE 13 wAC'vER SSUC. i , ` r a 2 �?� LEVEE STAB:-E • r c,,. _. N O. 1142 4' i 7 K 4i'S k i,F RE BY N LC.+��h :h'ALL A.'I LY. TES S TO 6% CEh?E..ED UNDER Af4.Yh'OLE COVER. �s� , S" �J�R I ;w SASE rim+-IfTr:�''�._�•'�J` 7 71 , I. ALL FIrL CO!,' ECTIO'�S A':D CO,%CPETE CON- t. P.FC0.41MENDED MANUFACTURER - ROTONDO OR t._E"�:,� •T� STnC'CTIG4 TO BG' iiAiEr'Tt,; T. APDP,OVED EQUAL CROSS SECTON VIEW !-V2`- 3A s SEPTIC TANK METAL NO. OF G.4' LONS: 1500 D STPI3U I �e�' 1.' :�OX D=TA L EACHII�G GALLEY DETAIL L iy M .AP NOT TO S;ALE - - - F,OT TC SCALE NOT TO SCALE SCALE 1"=2083 10 B GT T V M OF HC L 91 2! 10 NO WATER ,_ 11 ENCOLZITERED 11 SYSTEM PROFILE DcSIGI'v' A*�f,l';! NOT TO SCALE 12. 12 DESIGN FLOW: P 676t l-�'LE ANC Cvy'ER DATE. DATE , T�` �!NIS-4ED GRADE c EL ' �" MT FINISH vRA;7E TG HAVE MIN. 2% 4 9._ti n C JMS X !10 G P . = 4•� SLOPE OVER LEACHING FACILITY TES? er: - - - TEST SY: ' FINISH GRADE - _ Pra�ect T�;iti. MJrC ,'_VAN WITNESSEn JtT WITNESSED Or: — - - SEf lIC TANK REQUIREMENTS. -}� --- -- FIRST -WO FEET GERRY :' 'N.":EN:� I/T' `F' - ---a• E L :-EVEL _ 7 PERC.. RATE. �, ------ -_- _ 2„ A S ONE 4 4 O X 1.5 - 6 60 _ USE i500 GAL. rt�C. RA rE.• � ��-- -_79 � M . - _-_..__-- .--- �,,_ ' ^„ .� � _ N STREET �2 ,tflti,/INCN �tN,/IhCA 98 04 7.6 1/4 /FT -�► - °� _ -_- �04J MAC -- f j C- ,/4 -f 1/� NASHEC STONE i 0c GAL i '3726 0 329 _ BARNSTABLE, MA TP No. TP No. • i R:ENFGRCEC CCNC. _ (OSTERVILLE) EC E ` SEPTIC TANK BOTTOM EL= 93.97 - GR DEL. GRD-EL _._ ,_ OF G{i'.EL. GK'-EL. r 7G BE INSTALLED AON A LEACHING GA`�EY -T - EFr --�-�-� •• LEVEL, S B`E SE G 0 ,T,7� 1---7-T-� LEACHING FACILITY P.EQUIRFA?EA. S. SEPTIC 4x4' GALLEY A TH 2' STONE SYSTEM UPGRADE S;CE AREA = 6.6 (2.5)= 16.5 GPD/LF 2 --.,.. -TOLN AKEA= S.0 (I ? = 8.0 GPD/ _F74 . 3 3 � - !`" �t •---=_.� - '_ �\ ._ 14 .6 SF./L F 2 4.5 T GPD/L.F _ ' 76 _.._245 GPD. ' F = 179' , PF.;?t IDF_D: s ` / 5- 1' �:._; E rC. ru.TH 2' S 7 0 N E - M 91 62 '^ �\ � >4 �-L) CA,- _LIT Y 440 GPO , +-E S 7 r �< �4 ISLE' .NOTED ALL COh�'7 Rt I;vf�S ANtiI) A!ATF_R!4LS SHALL CO.' t`•. R' ? O Tl i c.E { rtJ+F .r'iIL ST•tT£ E.►.'{ IRfa' - +rF%7.t1. CODE_ AND AP0' APPLICABLE LOC 4!. r. t \, RULES AND REGULATIONS. i -- - 1 �O 1 GRO(T TO BE USED AT ALL POINTS WHERE 9 PIPES Eh'T£R OR LEAVE ALL CONCRETE ' �. ' �' STRUCTURES IN ORDER TO PROVIDE A �+ATEF- - ___�`I h /;�*'CN or S 4 - , --� - + TliirT SEAL. Lis F _-EX!Si-'��� ` f�TEfvl 3 ALL SHIPLAP JOIATS IN SEPTIC TANK SHALL A. M. WILSON, ASSOC. !NC. - 9 0 --- ,_ _�.' FE R -._ `- 84 BE Si L£D {;'ITIf l,'EOPF F..'�'£ GASKETS OR LT CE,kfE DT TO PRO► I DE A R ATERTIGHT 911 MAIN STREET ASPHALT g t , - qg �86SEAL. TERVILLE, MA. 4 ,iVER I LL OS ~� 4 PRECAST CO.'�'CRFTE SEPTIC TA.�'f • DISTRIRU- 428-1450 TION BOX. AAD LEACHING FACILITY TO R'ITII- 4' ;:4 'El? AT BL'ILI�I.ti'G8.5 _ r �.•_ �\ 88 t STAND H-/0 LOADING UhLE;S L".D'L'E P.4{'£- i EA. }T,iu' y8 -_,tea- � ��. � AtEhT. DRI{'£S OR TRA{'ELLED WAYS { HEREIN !" INVERT AT SEPTIC TA.'�'x :'ir 9F C:�+ - J;.'-D'tl^ T`- '� \�\'� H-20 LOADING SHALL APPLY. £. 1 -_.. - PREPARED FC)R ' �r 'ter Sr - � 9 \ 5 ALL PIPES IN THE SYSTEM SHALL BE SCHrD- 1 0",% 'ER.T AT SEf 7 IC TANK (Oul) g7.79 _ s ' � `-� � � � � � � � 9p ULE 46 OR EQUAL. -- ;. :'ITI; N PR-1 CS - • A1;�:. DR V 4' INVERT 4T DI..'3 i . PDX 00!1 _ 97 i t 6 WASHED CRUSHED STONE SHALL BE FREE OF AYLCRO REALTY � 4' I;'�'7'ERT AT DIST. hOX' !GR4tI 97.44 � ' \ � � ALL DIRT. DUST AND FINES. ! • 94 NO WORK TO BE DONE IN THE 100' AT ALL POINTS OF INTERSECTION OF WATER l;ti'i'ERTS AT LEACHING FACIL .TY: '- - \ ` -� WETLAND BUFFER WITHOUT AN LINES AND SEWER LINES. BOTH PIPES SHAI L T _ ` \\ _. � \ ORDER OF, CONDITIONS. PIPE AND APEED OF CLASS TO BE PR£SSUREOTESTEDURO I 4' I.' FERT AT BEGI'4NI'�'G OF ;------�-� F LEACHING FACILITY' QT2t j 96 ASSURE WATERTIGHTNESS. Drawing Tile 8 SEPTIC TANK DISTRIBLTION BOX. ETC. 4' I,'D-{'ERT A T £h'D OF t s ;L j t S E MANUFACTURED TONDO OR I LEACHING FACILITY N./A r 1 �:..___ ____-_. � ,`_ 4 AN EQUIVALENT LENT MAh'G'FACTUR£R. �� ,,1;; pp : T BO:TO;f OF _ I �\ 1 b u" V ELEVATION A 9 j 97 , s _. �� 9 £1'CAt'ATE ALL UNSUITABLE MATERIAL 1:N `'' ` I LEACHING FACILITY a EXIS" r� •' '� _. LEACHING AREA AND BACKFILL WITH CLEAN GRAVEL OR COARSE SAND. e r :^•^"' DESERVED GROUND WATER � 8_'!i ClNG ! � � � ELEVATION -. /A 1C� HEAVY £QL'IPAtEh? SHALL NOT BE ALL0I4"£D TO OPERATE OVER THE LIMITS OF THE SEWAGE DISPOSAL SYSTEMS DURING THE �S�''"`� �R � COURSE OF CONSTRUCTIOS OF THE SYSTEMS �✓ !+�P AL L; +�c' a �- x II NO FIELD I{,ODtFICAT'IONS TO THE SEWAGE DISPOSAL SYSTEM SHALL BE MADE WITHOUT ! W ( \ PRIOR F!-RITTEN APPROVAL OF THE ENGINELR ���' AND THE LOCAL BOARD OF HEALTH. g/ ROBERT Gr. 99 11 THIS SYSTEMSHALL BE IA'SPECTED AS RE- �' \, C N+'TE: N - .DERGROL)ND UIRED BY SECTION Z.IO OF TITLE V. ��1f I 101 ; ;�I71ES A�PROXIM•�TE AND SHOULD Q - 9�( �. 1 + 8E VERIFIED IN THE FIEF D BEFORE 13 A CERTIFICATE OF COAfPLIANCE AS RE- 3 \ \� „�` �.�--i .��, r- CGNSTRJ �TICN. QUIRED BY SECTION 2.8 OF TITLE V MUST BE aM OBTAINED BY THE COATP.ACTOR UPON COAT- P�tOPOSED CONTOURS PLETION OF THE ABOVE WORK. IF AN 'AS _ - _ - BUILT' PLAN IS REQUIRED DUE TO C014TRAC- A 5 NOTED EXISTING CONTOURS TOR DEVIATING FP.O.Af THESE PLAID'S, R"ORK FOR SUCH "AS BUILT' PLANS SHALL BE � F.,_,-,.,�'�''�X��",..�:y� • '-.• g3 COMPENSATED BY THE CONTRACTOR. 0 FEET ' �'���E I"=20' w_ PEA I (+� S-�- P GET 14 THIS SYSTE.4f IS GAF.BAGE DISPOSAL ENO T DESIGNED FOR A Date: I0/2 9/67 Dwg No - 13 ALL ELEVATIONS ARE BASED ON AN ASSUMED Desion: M J D. D ATU.A,!. Cro_-k: Drawn: M,l.D. 1 JY) MO: 2 0i46 O Sreet I of I , E