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HomeMy WebLinkAbout0007 MAYFLOWER LANE - Health 7 Mayflower L.aTie osterville . ' '�- A=140-116 I i I I I J lJll o � No.2.15 321LGN HUTINGS,MN y N NAd I 3p Am,OF BARNSTABLE' LOCATION SEWAGE # VILLAGE 1,0?4,44 ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. Rv4-eA*R•Chu.Co.'4n. SO i-q::,z-D Sr3 o SEPTIC TANK CAPACITY W00 O tl-UE LEACHING FACILITY: (type) (size)JI- '06 up NO.OF BEDROOMS //�� BUILDER OR OWNER AU � zts, PERMIT DATE:_ COMPLIANCE DATE: U O 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 Nd GJ.�� 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 f}cility) 1V0 Feet Furnished by i r + a . I a I 0 9 Ry rn c x e � s TOWN OF ARNSTABLE /-AO Arf :LOCATION L a r CFI Z 4 SEWAGE # 'VILLAGE DS T L' IL/ �- ASSESSOR'S MAP LOT INSTALLER'S NAME & PHONE NO./ - / 6 SEPTIC TANK CAPACITY / -- ®d LEACHING FACILITY:(type)/,"/>c i� h��i (size) %o y d G� NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIP WATER y /� BUILDER OR OWNER /G DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No T,1� �� zq ,3 3S" o � t 3 02 o e /� I Commonwealth of Massachusetts H llb U W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Mayflower Lane-system #1 of 2 C Property Address Lois Dallow Trust v Owner Owner's Name information is required for every Ostervillev/ MA 02655 5/10/2016 _ page. City/Town State Zip Code Date of Inspection W Inspection results must be submitted on this form. Inspection forms may not be altered in Ny way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer. 61* K use only the tab 1. Inspector: key to move your cursor-do not James Ford use the return Name of Inspector key. Ford Septic Services, LLC rab Company Name P.O. Box 49 Company Address e«m Osterville MA 02655 City/Town State Zip Code 508-862-9400 S12482 Telephone Number License Number B. Certification 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 ❑ Fails ❑ Needs Furt Evaluation by the Local Approving Authority 5/17/16 Inspec o I Signatu a Date The s t m ins ector shall submit a copy of this inspection report to the Approving Authority(Board of Healt or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �o rS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Mayflower Lane -system #1 of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. City/Town 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. ❑ 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 7 Mayflower Lane -system #1 of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 15303(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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Mayflower Lane -system #1 of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. Cityrrown 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. t ❑ 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 1h day flow t5ins•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 A,•'•- 7 Mayflower Lane -system #1 of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number'of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or 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 ❑ ❑ 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 v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ''�M a,• 7 Mayflower Lane-system #1 of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. City/Town 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 ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 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). 440 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A,•°'• 7 Mayflower Lane-system #1 of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. Cityfrown 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for,Voluntary Assessments 7 Mayflower Lane-system #1 of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: unknown Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: , 1500 gallons How was quantity pumped determined? Reason for pumping: maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑` Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.�,•'' 7 Mayflower Lane -system #1 of 2 Property Address Lois Dallow Trust Owner Owner's Name required for is every Osteryllle required for eve MA 02655 5/10/2016 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: installed -9/28/1987 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 20"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal. Sludge depth: 2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments a 7 Mayflower Lane -system #1 of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osteryille MA 02655 5/10/2016 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 27 Scum thickness 3 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 12 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tees were present there were no sign of leakage The cover was 20" below. Grease Trap (locate on site plan): Depth below grade: n/a feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El 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 I Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° -A,•` 7 Mayflower Lane-system #1 of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 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 or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): N/a 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 7 Ma lower Lane.-sy stem m #1 of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. City/Town 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 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 normal. 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.): N/a " 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 1 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �Sy04'; 7 Ma lower Lane-system #1 of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1- 1000 gal. with 3'stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ 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 pit was dry and clean. There were no signs of failure A camera was used Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration n/a 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 Commonwealth of Massachusetts Title 5 Official Inspection Form J Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�A a,•'�p 7 Mayflower Lane -system #1 of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 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.): N/a t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �,•'' 7 Ma lower Lane-system #1 of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ProT a � 0 0 3 O A (3 0 13 ao a a9 C t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Mayflower Lane -system #1 of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 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: 25'+/- feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Topo and water contours map. ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above 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 b Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments aSVe',_ 7 Mayflower Lane-system #1 of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �a.a,• 7 Mayflower Lane-system #2of 2 Property Address Z Lois Dallow Trust Owner Owner's Name " € information is required for every Ostervllle r MA. 02655 5/10/2016 page. City/Town State Zi Code P 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:When A. General Information filling out forms on the computer, (� use only the tab 1. Inspector: key to move your cursor-do not James Ford use the return Name of Inspector key. P Ford Septic Services, LLC `tab Company Name P.O. Box 49 Company Address ret� t Osterville MA 02655 City/Town State Zip Code 508-862-9400 S12482 Telephone Number License Number B. Certification 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 ❑ Fails ❑ Needs Further, valuation by the Local Approving Authority 5/17/16 Insp is Signature Date The tem inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Av VS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M °p 7 Mayflower Lane-system #2of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. City/Town State ZipCode Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 y Commonwealth of Massachusetts ` Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Mayflower Lane-system #2of 2 a Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterv— MA 02655 5/10/2016 page. City/Town State Zi Code P Date of Inspection- Pump B. Certification (cont.) ❑ Chamber um s/al P p arms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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. t 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M a •`''p 7 Ma lower Lane-system #2of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. City/Town State 0 Code P 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 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °`M a 7 Mayflower Lane-system #2of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or 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 ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive.area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well 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 s. g stem has faile d.ed. The owner or operator of an large system considered a significant threat under Section E or failed under Section D shall u Y g system in accordance with 310 CMR 15.304. The system owner should contact the appropriate p the regional office of the Department. y t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °� a,•'�r 7 Mayflower Lane-system #2of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. City/Town 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 ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the,failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms 3 (design): Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M •'�- 7 Mayflower Lane-system #2of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. City/Town State ZipCode 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 information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ElNo Water meter readings, if available: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • as• 7 Mayflower Lane-system #2of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. City/Town State -ZipCode Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: unknown Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Reason for pumping: maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool. ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval.. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 7 Mayflower Lane-system #2of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 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: installed -8/8/2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 101, feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene Y El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal. Sludge depth: 1 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�. 7 Mayflower Lane-system #2of 2 Property Address Lois Dallow Trust Owner Owner's Name ' information is required for every Osterville page. City/Town MA 02655 5/10/2016State ZipCode Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 27 Scum thickness 1 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 12 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tees were present, there were no sign of leakage. The cover was 10" below. Grease Trap (locate on site plan): Depth below grade: n/a feet Material of construction: ❑ concrete ❑ metal ❑fiberglass 9 El polyethylene El 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 y Form - Not for Voluntary Assessments 7 Mayflower Lane-system #2of 2 Property Address Lois Dallow Trust Owner information is Owner's Name required for every Osterville MA 02655 5/10/2016 page. City/Town State ZipCode Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass 9 ❑ polyethylene El other(explain): N/a 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 °`�,-e>•`'•r 7 Ma lower Lane-system #2of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. City/Town 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 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 normal. 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.): N/a * 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7 Mayflower Lane-system #2of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gal. chambers 12x25 ❑ leaching galleries number: ❑ 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 chambers were dry and clean.There were no silgns of failure. A camera was used. Cesspools (cesspool must be pumped'as part of inspection) (locate on site plan): Number and configuration n/a 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 Commonwealth of Massachusetts e Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '`� �,•'•F 7 Mayflower Lane-system #2of 2 Property Address Lois Dallow Trust Owner information is Owner's Name required for every Osterville MA 02655 5/10/2016 page. City/Town State p Code Date of Inspection Zi D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failurejevel 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.): N/a l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments sessments `�A ®,•` 7 Mayflower Lane-s stem #2of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 page. City/Town State ZipCode Tate of Inspect ion D. System Information (con�t.} - Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Q ® 0 a a� 33 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments • 7Ma Mayf lower Lane_ system #2of 2 Property Address Lois Dallow Trust Owner Owner's Name information is required for every Osterville MA 02655 5/10/2016 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: 25'+/_ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Topo and water contours map. ❑ Checked with local excavators, installers-(attach documentation ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: see above 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 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 7 Mayflower Lane-system #2of 2 Property Address Lois Dallow Trust Owner information is Owner's Name required for every Osterville MA 02655 5/10/2016 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 No. `--� ' } Fee CLTH HE COMMONWEALTH OF MASACHUSETTS Entered in computer: Yes PUBLIC HEIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippricaor �igpogaf *potem �Con�truction Permit Application for a Permit to C )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. 14 C RyS tO L L A KC 9-0N D Owner's Name,Address and Tel.No. SD u-ly 14 0 S-3 OS-tE t-VI L L C I M9.55 Lo 15 41-LO W Assessor's Map/Parcel y 7 C r ystai- L a!G E Q-04 P MA Igo pArccj II to ASS. Installer's N Add ss,and Tel. o. Designer's Name,Address and Tel.No.6-0,9-4 2 fr- 3 3 4 tl SVLLII/AgL G/wilvc- -21 ll�P live- 1 / '7 PnrK E 2 2aA D asfErlii Z-L E �s s Type of Building: Dwelling No.of Bedrooms Lot Size 159 2 sq.ft. Garbage Grinder(P6 Other Type of Building BLD C. AAA/tio/✓No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 0 gallons per day. Calculated daily flow 3 3 2— gallons. Plan Date No✓. 2. I q 99 Number of sheets I Revision Date,yr�lt/1✓ Title 9 1-t F PI-PP - PAO Foss D S ytE I M ProL/,,=jnEiyr-r Size of Septic Tank /5�2o Type of S.A.S. 12')( 25'LEACA)6�2 eAAM13 Description of Soil 4-3"— 0— 0 0-aP yi e- In o tE21 Kl i- , 3'0 13"- ji-: — Brie. CaArsE SA&D, 13"- 4o" - B- BrAlisN V&L• co.4rSC- SAA112 46b- &0 C 1 - Lt.16121.SN Brly ec,414,­ S,9I'VD , 1,a"- I Z2'—C 2— L-t Yr=L!IS14 Bi'N i=f/1/E SANG Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d yjZdo ealth. Signed t Date Application Approved by 1 Date — Application Disapproved for the following reasons Permit No. 7-ofDate Issued :�.. -• ' "• 1. „ '`• .. \ Q 77 Y+ , ` . ,� Fee t CQT�H HE COMMONWEALTH OF.MASSACHUSETTS Entered in computer: Yes PUBLIC FEEIVISION -TO.WN OF-BARNSTABLE., MASSACH.USETTS 01ppYicar Mi5paal *proem eon�truction,-VermitApplication for a Permit to C )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. H C Ry5 t.41_ L4 ICE PZ0f D Owner's Name,Address and Tel.No. 50 S-y ZS" y $3 0S7t67ri/ILL6', /'Y 9_ss (-o is DA[.Low 4„ •_•w.;. >�Assessor's Map/Parcel L/7 C r y S ten_ L p i,-6 12 a,d n MAP 140 Are-CL 116 0Sf6r✓1c.L_& )rass. Installer's Nam Address,and Tel. o. Designer's Name,Address•and Tel.No.509-42 - 3 3 4 cl 2)U S4LLII/�A, GN6//VCE21 Nfi l/ilG IYt_vJ `7 P/9rk ER 2v-4 0 Type of Building: Dwelling No.of Bedrooms _ Lot Size 6' 9 2 sq.ft. Garbage Grinder(�V� ` Other Type of Building BLD 6. A0101 tio/✓No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3 D gallons per day. Calculated daily flow 3 3.Z gallons. Plan Date Wo V. 2 , 19 99 Number of sheets Revision Date,\_/crAl6 Title S ItE PLgV - PRoPOS&D S1-t6 IM Pro//E�Eyrs Size of,Septic Tank /5�)U ��4L1�/✓ Type of S.A.S. 12.'X 25'LE.4eAi& C�►�NtB�R Description of Soil 0-3"- 0- OI2Gp/L/c. InplE2lpt. , a If-13It_ E:- 13riv. CoArsE S,wi>D 13 4o" - t3- BriV'rs►/ y L. cas?rSF 5,0/PV , 40"- Ld�-- C( - yr.YEL'vsm BrA, t�prsc an-C2.-- Lt. YeL.iSH Sm. Ewe sA/vD 1 Nature of Repairs or Alterations(Answer when applicable) Date last,inspected: Agreement: } The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu d b Bof d o ealth. Signed =1 I kILA Date Application Approved by Date //'_7 Z" Application Disapproved for the following`reasons rr Permit No ?- 7 ! Date Issued //- Z 2 - 9 1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (fertificate of QCompliance THIS IS TO CE gqjFY.,that the On-site�Sew ge Disposal System Constructed(�O Repaired( )Upgraded( ) Abandoned( )by r' [� at LJ7 6 Iqsy r: QyAD has been'con'structed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ` 7eF.0' dated /,I- Z 7 - Installer Designer Sine a The issuance of thi e t shall not be construed as a guarantee that the e 1 �. fun io a� sig r - Date Inspector % A-ILI ---c-- (-7-------------------- ----- --- tad No. �7 ` � I' � — `- Fee �ffO. �•"r" THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1 Migoaf *pgtem Construction Vermit Permission is hereby granted to Construct(x)Repair( )Upgrade( )Abandon( ) System located at H I C r-YStPL Lq y6 Ro/4 D , Us7161-yt L-LE f In,gSs 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 st b completed within three years of the date of thisW Date: �=' Approved by4" 1 nn TOWN OF BAnRNSTABLE LOCATION H 7 C u.x SEWAGE # - 2,9 VILLAGE OA�a�, c%-tL_ h?4-4-fn ASSESSOR'S MAP.& LOT 7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /1�fI6vt LEACHING FACILITY: (type) ny (size)61'6'06 i NO.OF BEDROOMS BUILDER OR OWNER j PERMITDATE: /r—o2,2" 99 COMPLIANCE DATE: �'S 00 Separation Distance Between the: j . 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) NO W-dt� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300'feet of leaching f cility) NZ� Feet Furnished by _ ..... ....... ... ..... .. . 7-7..... - xn�) a e6l I , 51 :_4 nn No. Finc....'l:v�'L .... THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALTH a0 .•-•--•.....�.�. .n..............OF... Appliration for Disposal Works Tonstrnrtinn.prrmit Application is hereby made for a Permit to Construct (/ or Repair ( ) an Individual Sewage Disposal System at .... .... -- ...�,� .r-- ----------------------- ............................................... p ocation- dress or Lot No. (� Owner Address a ( 1 .................................................... .......----............---•--.. Installer Address AA UType of Building Size Lot_ �Ja_ -4 ._..Sq. feet Dwelling—No. of Bedrooms_____�.................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of ersons_____II � � YP g --------•-----------------•- P ►1�--.........------- Showers ( ) — Cafeteria ( ) QOther fixtures ....................----------------------•-••-------.-------••-••-------••--•------•-• ............................................................. Design Flow________________.S_rJ___..................gallons per person per day. Total daily flow..2.)30.....__._______ _........_�__gallons. WSeptic Tank—Liquid ca.pacit}j.FCQQ_gallons Length_b.ta"__ Width................ DiameterrL?. .'_ Depth l`.._. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.......�._�__s_�____....sq. ft. Seepage Pit No------I--------_____ DiameterA Z__0_....._. Depth below inletfi2__0.`.°....... Total leaching area�.`T�d.....sq. ft. Z Other Distribution box Dosing tank ( ) _ P-a 33 aPercolation Test Results Performed b}� _,5� ._ � _... Dgrate.+' .�_ F_-- a Test Pit No. 1.....�g.-_......minutes p er inch De th of Test Pitt..................Septeh to ound water_)'1. f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Pi .-•--••....................4---.-------•-•----........----........___....._........_____----_•__---____ O Description of Soils _Z,'� ? .SU k)�_l___. •--- W ---. .....lD.`" l �...[Y e cl+v�! %t�l�._ ��t%1� ----------------- - ----•- 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 TITU 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 oard ,-hh 9 Signear� _:..�i�� ✓_ _______ -----------•--------- . . •---- ..... �� Application Approved By.......... _._ • Application Disapproved for the following reasons:----•-------•----•----=----••-•-----•------------------•----•--------------••----------.._......•---•-------•-•- •--••-••........•.............. ----..._ Date PermitNo...- 7.. ' :77......................-- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ------ .6 .n.............OF."... . Y15+"a Appliraiion for Disposal Works Tons rnriiun Vrrudt Application is hereby made for a Permit to Construct (V ) or Repair ( ) an Individual Sewage Disposal System at: , . �»::. .?........_..R .� ..... .:-- ....... --° .............................................. io - ddress or Lot No. ... » »..... •• ....................................... --•-...-•••--•-----•....--•••-••-•••-•••-•--••--•.....•----•-•••-•......--••-.................-•- n Owner --------••----._....--•--------.Address Installer Address U Type of Building Size Lot.`_` i.16614....Sq. feet ,-, Dwelling—No. of Bedrooms.....IC5.......................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building No. of ersons...._L0.................. Showers a g --•-----•----•-•--...---.... p ( ) — Cafeteria ( ) Otherfixtures -----------••-•---------•-•----•---•---------•--•-••----------•--•-•--•-----------•-----•--••--•-•--_---••---•-----------------------••............. Design Flow•.•....•....... �...................gallons per person per day. Total daily flow... ... gallons. w Imo its' ;----- •-------•-•-... ,'1 „ W Septic Tank—Liquid capacit§ -__----.gallons. Length__...__�Q..... Width................ Diameter-.�._--6....... Depth--:---...._. x Disposal Trench—No. .................... Wi ttl.................... Total Length.................... Total leaching area.......... sq. ft. Seepage Pit No.......t___.______. Diameter _.._. �__..__ Depth below inlet-��--�.�.I........ Total leachin areal q�_....sq. ft. Z Other Distribution box (�) Dos' Ig tank ,( ) Percolation Test Resul Performed b e.___r���� � �� Neu !�._ Date t`�h � �gig Test Pit No. 1................minutes per inch Depth of Test Pi&� .._..__.___.._. epth to ground water_n�'1:�----__. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P ------------------------•--------------•---••------------....--••---•----------------•--......................................................... 0 Description of S ' GV z Sl t b` .... ..... x -•-•-------------- Iq' t4` (Yle �-v-•-- 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 TITIL- 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 bo of h Signe ---•.. ................... .......... Date Application Approved By........7 =--=- """ -.-------•------------•-----------•---•---- Date Application Disapproved for the following reasons:----•--------•---•-------------------------------------•-----•----------------...-------------•-...------•....» --------------••----•-••-•--------•-•-------•--......------------•--------•-•--------........------.....-.•---•---•--•--•-•••---•-•------------------•--•----.._...-------------•---------•--•--...------ Date PermitNo.-�/ ...................7............................. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS 4- BOARD OF HEALTH .............................OF...........................................-&t:................................ Trriifirate of TompliFaatrr THIS IS TO C RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY--•-•-----------------�-` ---......--•------...............--------------...---------........................ . Installer at--•---..-- -•------------------••---•-------- } - has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..._ 7'a 7.�_.._ . . __...___. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......................•.....( .. ... . Inspector.................... c THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH hh 7-x7/ ............. . :..:.......OF..........1 .................................... No......................... FEE2:6......: Disposal Narks Tnntrnrtion rrnti# Permission is hereby granted -----•----------------.---•-•----...------•--•----•--------•--•---......------•--........-•--..........•-••.........•. to Construct >(L or Repair ( ) Individual Sewa a Disposal System 7 at No..........L-® �� i .....-•---- ...................................--r.eet-----------------------•----••------------------•-•-.------......------......... Street c� as shown on the application for Disposal Works Construction Permit..NoP�- �r,�-..•.• Dated.._..-_9.............................. .....� ...— DATE .... ......• Board of Health L.� FORM 12$5 HOBBS & WARREN. INC.. PUBLISHERS O.� • ! 1 FG.29.0 FG 29.0 z } 27.0 26.0 Tcp EI.27.0 N 49032r30"E 109.54' _ ! 26.8 1500Gallon 26.6 _ Bot.El.24.0 __ X— Septic Tank 26.4 26 2 Ip' 2$X 0 # 5EPTie Bedding as 5.2� MIN. f TAN K. a 1 Per Till*S r - + — i 10� 10.5 10 10� ' 12t 8ottont of Test Kate El.18.8 + r NO Ground Water I Q looT, teseavG T.H. Ip EVELOPED PROFILE OF PROPOSE® SEPTIC SYSTEM -1 z►,e2 MIN _. . ..Not to Scale Na_ p-BOX n . ... L Wafer Supply ForThis Lot b Municipal Water. PR 1 MARy Finhh e.oae It I�owtian of Utilities ShownonThisPlan An Approx. .0 _ At Least 72 Hours Prior b Any Excavation rwThis •, ^ Project The ControctorSholl Make The Required filter Compadod Fill NotificationtoOigSateU-800-322-4844) . . .�► w . 3 The Contractor is Required to Secure Appropriate tit Permits From Town Agencies For Carletr�retlas Defined byThis Plan. �.-5LA8 siXIST. 4 Install Risers05RegduedtOWithin 12~ot PATIp _O p Finished Grade. Lesehlsg 3/0-1 1/!�: IL All Structures Buried Four Feet or Mare or Subject ` OC s« Chamber Stone 1NbrMd to Vehicular Traffic lobe H-20 trading. x 1 oo, r J 6.So tic System lobe installed in Accordance With I n I 4- 310 CMR 15.00 Latest Revision And The Townot W 12-o" Barnstable Board of Health Regulations EXIST. {{{��� I I pw 6 LL 1 N G F l: b 11r M n1 T. All Pipng lo be Sch 40 PVC. o CROSS SECTION OF CHAMBER DESIGN DATA_ O ^NOT Th SCALE House Additi Minimum Design . O With°no Garbage Grinder C O Dailyy Flows 330 GPD O SegcTank=330 GPD x 200%s660 GPD — Use 1500 Gallon Septic Tank r + 'f'1EST HOLM- Es•. 'r'EST HOLE gY LEACHING AREA 3 � 24.o SUL\.\VAM �; 330 GPD/0.T4=446SFRequired O IaNG1NEER\t�►C*•it'C., Sldswall s2(12'+25�)2s146 S.E O ANIG MATUlk%*AL M � • O ORG NCV, {) 1999 ' Bottom Area= 12x25 = 300 S.F. 3` MO GRout4o W/► ed 'rI'R 44 LEACHING CHAMBERDESIGN . a BRN. COARSB SAND R O r —- -� I C 1 OY R 5/'S 1 All Pipes lobe Schedule 40. 2-500 Gol.Leaching Chambers Ino le s 2S Washed Stone Field as Shown CO AR Z SAND 5 01 R b/b Li -I EL ISN SRN•coA.R6E The Proposed toundation shown hereon complies G� Cl SAND ►OYR (./s1 / isM (-"J�,' 1,`Ac EA �o'' F\ s with the sideline set back tocated within the 00 Year c LT,yEI:\aN BR1.1. N of Barnstable an not r<1t15t. $EpS1L Sd5 15 `,2 ZO fist \N SAND 10YR bfN floodpiain. r '122u _ _ w� SITE PLAN ��P�`H OF .M � Vie:�,e' _ PROPOSED SITE IMPROVEMENTS h � A — '� $44°18r00r�W 110.00 cov o` DAMES � AT - ROAD , o C. ' ; ry. d e 47 CRYSTAL LAKE ROAD SjAL RE LAKE U NMo�33253 i .�41y1t �� OSTERVILLE ,MASS. CRY �a Zoning=RC '^ FOR PLAN VIEW Setbacks "� �isrEe :r w LOTS DALLOW Scale:Irr=20, Front 20� 1 © SCALE: AS SHOWN DATE NOV. 2 ,1999 Side 10, SULLIVAN ENGINEERING INC. Rear 10 MASS. e E R TERVILL OS , �go -78 I.......... t'SYS NOT TO:,S- C LE tFrNrSH "ORADE FrNrSH,:&QADE,,� OVER tFl C>FrNSH GRA O VER,DE,: NISH GRAL)E, OVERI�t '40 7/%\\ 11M 'LEACHING PIT t.o..U .0 VA A\NN RrA 1A 3 ,� OF 1/8 PRECAST lCONC .. :'OR:PEA S fONE BRICK & AfOR TA R,tOUTLET PIPE 3 0 12 BEL ON GAADE tFOR FT. MIN.0:,6 IIIF PVC TEES.. .d C. I.� OR-6 tBS,4f 7 #`L . GALLON EL . DISTRIBUTION BOX, I6 INSTALL ON. LEVEL 'BASE 14 7*0�3 PRECASTIoONCRETE PRECA T WASHED H—'10 tCRUSHED CONCRETE STON t 0 REINF H NK SEPTIC ' TA INS TA L L ON L E VEL, BASE No EXCA VA TE TO ELEV' OR RE L ONER TO , MO VE A L L IMPER VIOUS MA TERIA L BENEA TH THE LEACHING AREA REPLACE EXCA VA TED MA TERIA L #1 TH tCLEAN, CL A Y 'FREE SAND :ca EFFEC 7*1 VE \61A ME TER tES . LEACHING . , Pr-T GENERAL NO T t-INSTALL ON LEVEL BASE 1. ALL "ELEVATIONS SHOWN A RE BASED ON S-S'a/V 2. ALL-�PIPES IN THE S YS TEM 'MUS T BE 'CA S T ZRON TrON -PI T OR SCHEDULE 40 ,P VC. 08SERVA THE BOARD� OF HEA L TH,MUS T BE NO TIFIED 3 HEN CONS TRUC TION IS CO,4fPL E TE PRIOR 1313 TO BA CKFIL L ING PERCOL A TION:RA TE:ANY CHANGES IN'THIS PLAN MUST- BE APPRO IM 1N.VED BY- THE�BOARD OF-HEAL TH AND CAPE & ISLANDS wr TNEssED B Y.-SUR VE YING CO INC.0 5. MA TERIA L S A NO INS TA L L A TION SHALL BE :IN. 0 0 COMPL A NCE #I TH THE STA TE SANITARY -DESIGN DA TA 8RD. OF -HEAL 7N,DA TE:CODE, 7I,7L E V - AND LOCAL PPL ICA BL E,, ,RULES AND REGULATIONS . : NUMBER,, OF ,BEOPOOMS 6. NORTH ARROW' 15 FROM RECORD PLANS AND IS NOT TO BE USED FOR SOLAR PURPOSES GARBAGE DISPOSAL AIL Y FL ON AZ to 7. FL 000 H A RD ZONE C. GAL . - -GA L .t 8. A TER SUPPL Y 7o o*,y- Wp?i c e 0 SEPTIC TA NK REQ 'D. 'GAL TA Nk PRO VIDED 4 �cl SEPTIC , GPD.,LEACHING REQUIRED itISIDENALL AREA 'S.F.s L L ON S. F.X Z, G/S. F.S T CONCRErE SEprrC TANK : BOTTOM AREA , 11,3 S.F.'LEGEND In Iml. _LI:Z_S. F. F. �/,3* GPO LEACHING PROVIDED GPO PROPOSD EL EVA TION EXIS TING CONTOUR SEPTIC S YS TEM UPGRA DE ,OBSER VA TION PIT 0 DIS TRIBU TION BOX PROPOSED SEXAGE DISPOSAL S YS TEM tFREcAsr coNcRETE LEACHING PIT PREPA RED F04"L EA CHING F1 T 0'2? 4t!P Of Z>tSEPTIC TANK ,:'PICHAD DALLOW .t55 MA YFL OWER LANE,tRpl RESERVE 4o , LOT, t0.3 TER VIL L'E, tBARNS TA BL E, t"MASS.PIPE IN VER T EL E VA TrON r c4A f ARI DA TE: 4.�A- CAPE" 6 ISL,ANDS SUP VEYING, INC.,_::PLOT PLAN SCALE AS %NOTED SCA L E., I P. 0% BOX 334 It 'E TEA�PLAN-, ,NO t_c .0 e,MAP vS M_PCL