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HomeMy WebLinkAbout0030 MAYFLOWER LANE - Health 30 play 1ow.erw.= van f cgs ti9 A> ..140---122 tA- a a.t.3 a sa A'1 L".f1 �2 Fut { d i i f f io I d o c i i 1 i Y i i 1 i i i i I i i i I r l � 4 i r i TOWN OF BARNSTABLE y� �f o)b LOCATION yD LY, �4Y F�tw�Gr ! SEWAGE # J•�� =�� VILLAGE D:EC d1 G AAA Os1? ASSESSOR'S MAP & LOT r 21STALLER'S NAME&PHONE',NO,,-7z> 1 C1cnht Al Z j&?a,Z-7/77 SEPTIC TANK CAPACITY LEACHING FACILITY: (type (size) NO.OF BEDROOMS BUILDER OR OWNER ASS . t vaLt��hGt ta1� 'PERMPTDATE: U COMPLIANCE DATE: 111 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 hC h� Ol tile a 0 ��r• W c� dcm Commonwealth of Massachusetts �/_f0- 0202-- �. Title 5 Official Inspection Fora 1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Mayflower Road Property Address William Marth Owner Owner's Name / information is Osterville ✓ required for every MA 02655 11/24/20 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:When A. Inspector Information c51*- f a-U filling out forms p 0 on the computer, use only the tab James Ford key to move your Name of Inspector cursor- not Ford Septic Services, LLC use the return urn key. Company Name P.O. Box 49 ue Company Address Osterville MA 02655 City/Town State Zip Code reaan 508-862-9400 S 12482 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. Fails 11/25/2020 Inspecto ignature Date The sy to inspector 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Mayflower Road Property Address William Marth Owner Owner's Name information is required for every Osterville MA 02655 11/24/20 Cit /T page. City[Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: 2) 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): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Mayflower Road u Property Address William Marth Owner Owner's Name information isequired or every very Osterville MA 02655 11/24/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. -a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts fo Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Mayflower Road Property Address William Marth Owner Owner's Name information is required forevery OStervllle MA 02655 11/24/20 page. CityrFown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the,system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts 9 p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Mayflower Road Property Address William Marth Owner Owner's Name information is required for every Osterville MA 02655 11/24/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 30 mayflower Road Property Address William Marth Owner Owner's Name information is OSterville required for every MA 02655 11/24/20 page. Cltylrown State Zip Code Date of inspection- C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of i 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)] r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Mayflower Road Property Address William Marth Owner Owner's Name information is required for every Osterville MA 02655 11/24/20 page. Cltyrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Description: Number of current residents: 0 Does residence have a garbage grinder?_ ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection 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: unknown Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Mayflower Road Property Address William Marth Owner Owner's Name information is required for every Osterville MA 02655 11/24/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: 2019 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: • gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Mayflower Road Property Address William Marth Owner Owners Name information is required forevery OSterville MA 02655 11/24/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of,the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: installed 1/6/2005 per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade:' feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet , Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form X Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Mayflower Road Property Address William Marth Owner Owner's Name information is Osterville required for every MA 02655 11/24/20 page. CltylTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12" 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: 2000 H-10 Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle 28 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 15 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 Tee's were present. There was no si n of leakage The covers are too grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Mayflower Road Property Address William Marth Owner Owner's Name information is Osterville required for every MA 02655 11/24/20 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene y El other(explain): N/a Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): N/a Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts I9 Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Mayflower Road Property Address William Marth Owner Owner's Name information is Osterville required for every MA 02655 11/24/20 page. Cltyfrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): N/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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. Speed levelers were present t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Masgachusetts Title. 5 l)fficial Inspection Form Subsurface Sevyage Disposal System Forts _ Not for voluntary Assessments � 30 Mayflower Road Property Address William Marth owner, information Owner's Name i tion n um is pstervllle 9 d for every MA 02655 11/24/20 page. Cityrrown State ZipCode Date of Inspeaion D, System Information (cont.) 10, Pump Chamber(locate orl site plan): Pumps in wgrking order: ❑ Yes ❑ No* Alarms in wgrking order: ❑ Yes ❑ No* Comments(note condition of pump charhber, condition of pumps any appurtenances, etc.): n/a * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4-500 gal. drywells 13x42 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields' number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Mayflower Road Property Address William Marth Owner Owner's Name information is required for every Osterville MA 02655 11/24/20 page. Cltyfrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The drywells were dry. There was no sign of failure A camera was used 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): n/a t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 r Commonwealth of Massachusetts -. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Mayflower Road u- Property Address William Marth Owner Owner's Name information is required for every OStervllle MA 02655 11/24/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: N/a Dimensions i Depth of solids . Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2o18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Mayflower Road Property Address William Marth Owner Owner's Name information is Osterville required for every MA 02655 11/24/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately L I Porch •�B t o a 3 S o • /� 6 / /S /7 , aayaY 3 2� 3y • � ya S3 • s, S7 �S. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' b Susurface Sewage Disposal System Form - Not for Voluntary ry Assessments 30 Mayflower Road Property Address William Marth Owner Owner's Name information is Ostervllle required for every MA 02655 11/24/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 28 +/- 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 maps ❑ 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 i Commonwealth of Massachusetts Title 5 Official '- � ciallns Inspection Form X Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 30 Mayflower Road Property Address William Marth Owner Owner's Name information is OSterville required for every MA 02655 11/24/20 page. Citylrown State _ Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification:Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal.System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments David Lissy Property Address 30 Mayflower Ave. Owner Owners Name_ information is ren uired for every OSterVllle MA 02655 8/15/2013 page. City/Town 7 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:When A. General Information filling out forms (� on the computer, \i use only the tab 1. Inspector. key to move your cursor-do not James Ford use the return ., key. Name of Inspector . w crab Company Named P.O. Box 49 Company Address return Osterville - MA . 02655 C City/Town State Zip Code 508-862-9400 S12482 "� Teleph6ne Number License Number rrr B. Certification I certify that I have personally in`.spected 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 ' 1 8/20/13 Ins tor's Signature Date Th ystem insp ctor 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. F ""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. d q10113 t5ins-3/13 Title 5 Official Inspection FffSuface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 OfficialInspection Form Subsurface Sewage Disposal System. Form - Not for Voluntary Assessments David Lissy 4 Property Address 30 Mayflower Ave. Owner Owners Name information is required for every Osterville MA 02655 8/15/2013 page. City/Town State Zip Code Date of Inspection B. Certific ation c( ont.) 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. Y *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): Y t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments i 9 David Lissy Property Address 30 Mayflower Ave. Owner Owners Name information is Osterville required for every MA 02655 8/15/2013 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 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 I - ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official: .lnspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. a David Lissy Property Address 30 Mayflower Ave. Owner Owner's Name information is required for every Osterville MA, 02655 8/15/2013 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: . a ❑ 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 aseptic 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: k D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" o',r":No"to each of the following for all inspections: Y Yes No u ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® 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 15ins-3/13 / Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fdrr Subsurface Sewage Disposal;System Form - Not for Voluntary Assessments . David Lissy Property Address r 30 Mayflower Ave. Owner Owner's Name information is required for every Osterville i MA _ 02655 8/15/2013 i 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. El ® 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. r , El ® 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 amihonia 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 havedetermined 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 ystems, you sn Section D. must indicate either"yes" or"no"to each of the following, in addition to the questions Yes No ❑' ❑ the systte'm 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 )WPA)or a mapped Zone II of a public water supply well If you have answered "yes" toany 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. t t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massacihusetts Title 5 Offic.i.al Inspection Form - Subsurface Sewage DisposaltSystem Form - Not for Voluntary Assessments ,r I David Lissy i^M I Property Address 30 Mayflower Ave. Owner . Owner's Name information Is required for every Osterville MA 02655 8/15/2013 page. City/Town State ZipCode ode Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: tl Yes No 1' ® ❑ 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,thesystem 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? s built plans of the system obtained and examined? (If they were not ® ❑ Were a available note as N/A) 4 ❑ ® Was the facility or dwelling inspected for signs of sewage back up? d ® ❑ Was the site inspected for signs of break out? � i ® ❑ 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? i EJ ® 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 beemdetermined 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,):; 5 Number-of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 1 .' , IE Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage DisposalSystem Form - Not for Voluntary Assessments David Lissy Property Address 30 Mayflower Ave. :. ,. Owner Owners Name information is required for every Osteryille MA 02655 8/15/2013 page. City/Town State Zip Code. Date of Inspection D. System Information, Description: • e• i • Number of current residents;. . unknown Does residence have a garbage grinders ❑ 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? r El Yes ® .No i r Water meter readings, if available (last 2 years usage (gpd)): Detail: , unavailable Sump pump? El Yes ® .No Last date of occupancy: . currently Date Commercial/Industrial Flow Conditions: . Type of Establishment: Design flow(based on 310 CMR 15.203): " f - Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.):' Grease trap present? ❑ Yes ❑ No Industrial waste holding tank' 'present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins-3113 ? ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 0 Commonwealth of Massachusetts Title 5 Official; Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments David Lissy Property Address a 30 Mayflower Ave. Owner Owners Name information is required for every Osterville MA 02655 8/15/2013 page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) Last date of occupancy/use: f Date Other(describe below): General Information Pumping Records: Source of information: unavailable 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 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 off the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 • Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage DlsposallSystem Form - Not for Voluntary Assessments David Liss 4„M Property Address 30 Mayflower Ave. Owner Owners Name information is required for every Osterville MA 02655 8/15/2013 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) , t Approximate age of all components,'dateinstalled,(if known) and source of information: installed - 1/6/05 -per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 23' feet Material of construction:, ❑ cast iron ® 40 PVC r ❑ other(explain):. Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence-of leakage, etc.): 1 I • Septic Tank(locate on site`plan): r Depth below grade: 13 a 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 F Dimensions: 2000 gal. Sludge depth: , 2" l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts W Title 5 Official- Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments David Lissy Property Address e 30 Mayflower Ave. Owner information is Owner's Name required for every Osterville MA 02655 8/15/2013 page. City/Town r 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 15" Scum thickness 1 5" Distance from top of scum to top of outlet tee or baffle - 5 Distance from bottom of scum to bottom of outlet tee or baffle 15" 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.): There were no signs of leakage. Recommend pumping every 3 years. Note. The pool cabanna flows to the tank. 1 Grease Trap (locate on site plan): Depth below grade: feet Material of construction: l ❑ concrete .❑ metal : ❑fiberglass ❑ pot eth le-e Y Y ❑ other(explain): N/a 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 r Commonwealth of Massachusetts Z Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments David Liss Property Address 30 Mayflower Ave. Owner Owner's Name information is required for every Osterville MA 02655 8/15/2013 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.): q . i Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: I Material of construction: ❑ concrete ❑ metals ❑fiber lass g ❑ polyethylene ❑ 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? El Yes ❑ No' E , t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts r Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments David Liss " Property Address a 30 Mayflower Ave. Owner information is Owner's Name required for every Osterville MA 02655 page. Cityrrown State 8/15/2013 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 liquid level in the D- box was normal. f ' . A i Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No* Alarms in working order: . ❑ No" ❑,.Yes Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): N/a y * 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 David Liss J Property Address 30 Mayflower Ave. Owner Owners Name information is ' required for every Osterville MA 02655 8/15/2013 page. City/Town State ZipCode Date of Inspection D. System Information (Cont.) Type: ❑ leachingits,. P number: ® leaching chambers number: 4 -500 gal drywells 13'x42' ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields nIJmber, dimensions-, f . ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: i, Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There were no signs of failure. A camera was used for the inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 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 f > l - I i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments, David Liss Property Address 30 Mayflower Ave. r Owner Owner's Name r in formation is required for every Osterville MA 02655 page. City/Town 8/15/2013 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.): ,f 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 f t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts u Title 5 Official Inspection For Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments David Liss Property Address 30 Mayflower Ave. Owner Owner's Name information is required for every Osterville MA 02655 page. City/Town 8/15/2013 State Zip Code. Date of Inspection D. System Information (coat:) Sketch Of Sewage Disposal System: Provide Idea v lew 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 Poo CA6AAAA P wl . . 3 F0 AT +i a aye ay - s 3 3y., 3y a y ya S3 S !Sins•3/13 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 David Liss a Property Address 30 Mayflower Ave. Owner information is Owner's Name required for every Osterville MA 02655 page. City/Town 8/15/2013 State Zip Code Date of Inspection D. System Information (cont.) Site Exam: t _ ❑ Check Slope , D' ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 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 9 butting , (� g property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Using topo and 'water contours maps ❑ Checked with local excavators, installers -`(attach documentation) ❑ Accessed USGS database-explain: t You must describe how you'established the high ground water elevation: see above a • 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 • Commonwealth of Massachusetts m Title 5 Official: Ins Inspection Form m Subsurface Sewage Disposal System Form Not for Voluntary Assessments David Liss Property Address 30 Mayflower Ave. Owner Owners Name information is required for every Osterville MA 02655 8/15/2013 page. City/Town State Zi Code p ' Date of Inspection E. Report Completeness-Checklist ® Inspection Summary: A, B,C, D, or E checked ® Inspection Summary Di(System Failure Criteria,Applicable to All Systems)completed f' ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file F it 4. t i 9 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 No. FeeQ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppYicatiou for Mi5pogaY**p5tem Cow5tructiou permit Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ❑ Complete System individual Components Location Address or Lot No. -1jo v y ow4 r L.AbvQ Owner's Name,Address,and Tel.No. ?g I . q yy. 76l y 0 IZ ®5+rrvl1\f 'Qtavv � L;SS y Assessor's Map/Parcel Installer's Name,Address,and Tel.No. �� � Q?CO Designer's Name,Address and Tel.No. -775 `0735" -74V( - 6250.31�-3 vv e tit ef As 0 c. Type of Building: Dwelling No.of Bedrooms S Lot Size 1-7 sq. ft. Garbage Grinder Other Type of Building W®0 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) It; i7 0 gpd Design flow provided 51(06- gpd Plan Date 7IZqloq Number of sheets Revision Date Title 514t t �;?W 111 Q qN — MA rld t Lk 64 (V�1 Size of Septic Tank `Z 06 o A U Otif Type of S.A.S. Description of Soil AZ) O-er l of In Nature of Repairs or Alterations(Answer when applicable) �� nQ vu n L r „ Date last inspected: - Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by is oa a lth Signed Date Z7—Z 07 Application Approved by Date /(f 7 Application Disapproved by: Date. for the following reasons Permit No. 2W:7 — �2Uc Date Issued S I . THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that t e On-site Sewage Disposal System Constructed � Repaired ( ) Upgraded ( ) Abandoned( )by VA�r Co V at D L-ti (J t t has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 2( dated A —0 Installer , ` Designer #bedrooms 1"114 Approved desi n flow A/ god The issuance of this permit shall not b onst00 ed guarantee that the system I f nction de ig U' ¢Date Inspector No. . .CJ'� — ;;1 - 4.. Fee 7 V THE COMMONWEALTH OF MASSAi& IUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARN-STABLE, MASSACHUSETTS Yes ZIpplication for Migonl 4, p.tem CoH$tructioH Vermit• Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System Individual Components I � Location Address or Lot No._2jo / 1 D�� U1a�f ti�`�._ Owner's Name,Address,and Tel.No. 7 IK 1 • 4 qL • 76l y Assessor's Map/Parcel Ll 2 Z nn d Installer's Name,Address,and Tel.No. �{C q I(U Designer's Name,Address and Tel.No. -77S` d 7-2, Type of Building: 2 Dwelling No.of Bedrooms si Lot Size 1 I 1-7 sq.ft. Garbage Grinder (VJ) Other Type of Building W 0 0 t C-('aMy No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided S(6• gpd Plan Date _7/Z`6/0 1 Number of sheets Revision Date Title � i f t ';—eW,14CH Vk -27 0 AjA J -F(Owyf y 4-�(,Ji r,,t r( tt . Size of Septic Tank Z 0 0 0 y N I I a°^S Type of S.A.S. Q t f tt i T t Y V4`4 Description of Soil 64 ,; o-Pf V i H to 1 i Nature of Repairs or Alterations(Answer when applicable) vs,vik 11114 - 4`f. o e,u� f k10 ,(I r Date last inspected: 0S __ 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 iliZOV) _ nn Signed Date -Z`f' 0-7 Application Approved by U1,r. d'- Date �=/�- 7 Application Disapproved by: Date for the following reasons a, Permit No. 1 oo- - 2U( Date Issued 5716 It THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS ;A Certificate of Compliance THIS IS TO CERTIFY,that t e On-site Sewage Disposal System Constructed�( Repaired ( ) Upgraded ( ) Abandoned( )by C r C 0 at )-)Q M A 0 wff L—kN 05 4f f J t t has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7(k1 ' ��( dated S 16 7 Installer QQ Designer #bedrooms rj Approved design flow / gpd The issuance of this permit shall not bje /constr ed as a guarantee that the syste Fill function as deesigned. � /,G+� ,�12 Date _ ,� �'"7 ✓ a Inspector / / 1)/,;11C _4��s 1/ t r9��I/,�/� / t No, Ot)7 F Fee 1SL THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Migpont �&p5tem Cou5truction Permit Permission is hereby grated tq Cons ct ( ) Repair ( ) Upgrade ( ) Abandon ( ) I �P System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her dirty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this-pen Date Approved by , --' C. V F ' t J. r pp err, Li �l '� Syr 1I• t yyL f ' 1 t � �4 , I t i i e '• ;.�. t .. i° w' - JF_ ry 1. fl� 4.j V Ate ` .. 0,Nli �/ ✓ ! �4y 9' �-:♦'7�" 1 •'� �M i; .S'F ..�.. `, r+.i�,# ►k . f .'7Ri;t � a a, * j 4 � :.. �`. :.i�: �.k' a 1p �3 ��wK;��--.�}r��.,y 9�,.1� ��`�i������ �(�;}+��sf�ar�` � i. ��+�' c =� 4k `';. �• � . .rat • l ., j � } fit' •1 `« - � � i+i '�,"Y,� ��+'''+���� '� •A�,j„r #.. © � -r3 1� fir' f � ,.Rr rt f f - y i ij t 1 r` } �'�' Ml 1T h � r >. a r . i O 1 r' Go d • �4 L i"� r - � 1 .�- �.; kr,Ora" ..a • � r I to ' eah t }k �,._ � s� � try �agnri'� �y �� k"f• r� y, r 'P IfOL �� • . � tj asp '41,,4`4+.`.`" CA a•4 \J N9,@ V4 iY-P B o � { ROOF DECK o l=1 O no �s xwr a va•�va• �. cYJ 1 esY Vl MTTHI c y,• _ Y d�� 1a'4 a'-c• T_.• -THaIYi uric �.nlea.w moot �:. ? Ro ,,�•Q,,,,,,� ® BEDROOM #3 BEDROOM #4 - T MASTER SUITE CLOS w aunm it ua vo ImR.soVe we as tf+vn) a) •MA5TER ' euT a v.•m vv F f I2A t �. O ens#3 c� hICE - colon. li{ �� c at rvy col 4 a a ,. � � � � � a. .'M•..,yr °_•• i no+la---' LLl u BEDROOM *2 3 eon+m 'A k6 rnw N A Ll a'4 b4 i Z S'. �x s t= Td b�' Y4' Ys' •y1 nd@Q@ I•-Y ••-r n•-r 1r-Y .u'-r Y-w• A C5 a _ Q O F a rro � ��•'�t✓ aa y Rg DECK § t� GUEST SUITE 2A L F S F 7 `� F @S BREAKFAST tt 00 Q , • � � >a t GQ a f) (�� o I C}F2L sn - lJU p LnUN R7 ��•Nw�� _ O O SCREENED q taw I c.w eo rrr. PORCH * E FATILY ROOM 3 �' r nny C� N9 [ KITCHEN . I p° o� ✓-Y GARAGE r 1. F3 PORCH j a !Lb - ® iill ill e p i i i i III �� nL LIVING ROOM r�xr roW. PORCH �._, _ nn (aEucr'aq z° a .vn W n° FOYER Q Z N PORCH E 6 C S - Y W (L sd 14-"• �•e rs 1 Yb o' FIRST FLOOR PLAN sheer SCALE.11A'-1'-P P" NOTE: THE PLANS SHOWN ARE THE 50LE PROPERTY OF 26-0" 14'-O'± THE DESIGNER AND CAN NOT BE COPIED, (EXI5TING) (EXI5TING/NEW) REPRODUCED AND/OR ALTERED WITHOUT THE E%PRESS WRITTEN 1'-G" 1 I-O 1-G" CONSENT OF THE DESIGNER (5HED DORMER) 5'-G" W 00 EX15T. EX15T. EX15T. W Q OD zx m GAKAGE/DF JVEWAY VIEW �r cO m d A A4 ANDER5EN Ll d N TW 2431 O-2 z ¢ X U m p IV O r� PARTIAL SECOND FLOOR PLAN o W LEGEND ANDER5EN +I Z (� TW 244G-2 p z o EXISTING WALL CONSTRUCTION TO REMAIN EXIST. ROOM 0 F- TV ® Cm L NEW WALL CONSTRUCTION BEDROOM O (1 C=:1 EXISTING WALL CONSTRUCTION TO BE REMOVED GENERAL NOTES: Q oq o 1 .) CONTRACTOR 15 TO VERIFY EXISTING CONDITIONS AND o <� °6 -5 DIMENSIONS IN THE FIELD PRIOR TO THE START OF WORK - 2.) CONTRACTOR TO REMOVE EXISTING DOORS, WINDOWS, Q WALLS, * ROOFING AS REQUIRED FOR NEW CONSTRUCTION. W 3.) ALL NEW CONSTRUCTION TO MATCH EXISTING IN MATERIAL, Z cc DETAIL, AND FINISH. SCALE .4.) ALL WORK SHALL CONFORM TO THE MA55ACHU5ETT5 rANDER5EN 1/4"=1'-0"STATE BUILDING CODE (LATEST EDITION) AND ALL OTHER A 244G-3 APPLICABLE LOCAL CODES 7'-3" A4 5'-3" DATE 5.) ANY DISCREPANCIES, ERRORS AND/OR OMISSIONS IN THE NOTES, 1 1/I S/z017 I2O-G" DIMENSIONS, AND/OR DRAWINGS CONTAINED ON THESE DOCUMENTS 1-G" (SHED DORMER) PROD. NO. SHALL BE BROUGHT TO THE ATTENTION OF THE DESIGNER PRIOR TO COMMENCEMENT OF CONSTRUCTION. PROCEEDING WITH CONSTRUCTION 14`O 2017-579 CONSTITUTES ACCEPTANCE OF THESE DOCUMENTS AND ANY DISCREPANCIES, VIEW TO POOL DWG. NO. ERRORS AND/OR OMISSIONS BECOME THE RESPONSIBILITY OF THE BUILDING CONTRACTOR. O 5 10 15 20 ©COPYRIGHT 2017 Al 5Y THOMA5 A.MOORS DE51GN CO. S NOTE: THE PLAN5 5HOWN ARE THE 50LE PROPERW OF THE DE5IGNER AND CAN NOT BE COPIED• REPRODUCED AND/OR ALTERED WITHOUT THE EXPRESS WRITTEN CONSENT OF THE DE5IGNM Ocn O 7 U 00 �WQ Do NEW RAKE d DRIP BOARDS 12 Z :4 10 o TO MATCH EX15TING 3 O m 1 �EX15T' NEW ROOF 5HINGLE5 c N TO MATCH EX15TING NEW FASCIA 8 FPrEZE BOARD5 0 ¢ N TO MATCH EXISTINGLIJ TOP OF PLATE Z Q X 17- C/) NEW WHITE CEDAR NEW WHITE CEDAR W o O w ® ® SHINGLE SIDING TO L ® SHINGLE SIDING TO MATCH EXISTING MATCH EXISTING N o _D Q _ NEW CORNER BOARDS NEW CORNER BOARD5Q u~i TO MATCH EX15TING TO MATCH EXISTING F. LL-Li d:� LLI I I I I I J Bill 1[ 11!1 SECOND FLOOR 0 W SUBFLOOR 'Z' O Q O Q Z � � SCALE 1/4"=1'-0" DATE REAR ELEVATION i O . NO. POOL SIDE ELEVATLON PROJ. . 201 7-579 DWG. NO. O .. _ _ 5 IO 15 20 �� II ©COPYRIGHT 2017 BY THOMA5 A.MOORS DESIGN CO. NOTE: THE PLANS SHOWN ARE TnE 50LE PROPERLY OF THE DE5IGNER AND CAN NOT Be COPIED, REPRODUCED ANp/OR ALTERED WITHOUT THE E%PRE55 WRITTEN CONSENT OF THE DE5IGNER O M O V' C7 w T Lo G�c] 00 Q 0 00 NEW ROOF SHINGLES Z rn TO MATCHEXI5TING 3 O rn NEW FASCIA 4 FRIEZE BOARDS Q O TOP OF PLATE TO MATCH EX15TING f� v (� N NEW WHITE CEDAR ® ® ® ® ® SHINGLE SIDING TO N o MATCH EXI5TING0 = dw O N NEW CORNER 5OARD5 r TO MATCH EXI5TING Q SECOND FLOOR SUBFLOOR Q O _ FFH ® O — ==�= �==� Q � 0�0� DODO � -i F� F_77�4�F­l 1-] 4 cn SCALE 1/4"=1'-0" GARAGE 51 DE ELEVATION DATE: I I/I5/2017 PROJ. NO. 201 7-579 DWG. NO. 0 5 10 15 20 A3 ©COPYRIGHT 2017 5Y THOMA5 A.MOORE DE51GN CO. 1 4'-O"t NOTE: (EXI5TING/NEW) TneeuN55flO NARe THE SOLE PROPERTY Or TnE DE5IGNER AND CAN NEW ROOF CONST. 1'-G" o" 6" WRODUCOED AAND/OR 2 x 10 ROOF RAFTERS I G"o.c. (SHED DORMER) eXre 5—CN�OUT me @ C.5c5 WRITTEN CONSENT OF THE - I/2"CDX PLYWOOD ROOF SHEATHING DesiGNER A5PHALT ROOF 5HINGLE5 1 5LB.FELT PAPER A 8"MIN.SPRAY FOAM IN5ULATION Aq � ; o @ ROOF RAFTERS(R=49) Z -- -'I- 2 x 12 RIDGEBOARD u w r � ° TOP OF PL. 2 8' @ 16"o.c. — sse 00 NEW 1/2"GYP.BD.ON °° I �3: O rn I x 3 STRAPPING @ 16"o�". °°° NEW WALL CONST. - O a I 2 x G STUDS @ I G"o.c. -- - c o ✓o, '' NEW TV °°° 1/2"PLYWOOD 5HEATHING m O Q ° -G"GATT IN5ULATION(R=21) - O 0 N w ROOM °°° 1/2"GYP.BD. x Z r Iol W.C.SHINGLE 51DING w C7 m `IYVEK' ti] O w I EXISTING 5HEATHING - w S O rr 5ECOND FL. TO REMAIN,REMOVE C] F o. cc 5U5FLOOR EXISTING DECKING j OW EX15T.FLOOR JOISTS TO REMAIN +I I z Q c I � _ NE 2 x. 2 RI GEB AR _ p z rG Of I x Of EXIST. EXIST. WALL CONST. BEDROOM x Q o cl� EX15T.FLOOR JOISTS TO REMAIN Q o6 -j EXIST. A4 Q BASEMENT —EX15TING ON W ALT DORMER) 1 6 L5 (5HED OZ �O SCALE EXI5TING DATE CONC.FOOTINGS ROOF FRAMING PLAN 1 1/1 5/201 7 O. A BUILDING S TV NEW I V ROOM NOTE: ALL NEW ROOF RAFTER5 TO BE PROD.A4 2 x 1 0'5 @ I G" o.c. UNLE55 2017-579 OTHERWI5E NOTED DWG. NO. : O 5 10 15 20 �� ©COPYRIGHT 2017 BY THOMA5 A.MOORE DE51GN CO. No. �7 / ` - Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Ziopozal bpotem Construction Permit Application for a Permit to Construct('✓)Repair( )Upgrade( )Abandon( ) Complete System O Individual Components Location Address or Lot No. 30 /nA YFLd(1)L4 1-ANF. Owner's Name,Address and Tel.No. '79l ON- U/T Assessor's Map/Parcel d 5TZ/� 1 �1�I�j 14 "le. Installer's Name,Address,and Tel.No. s.Designer's Name,Address and Tel.No. .Tdrn kFAI�,C by 4 Type of Building: 33,y/7 Dwelling No.of Bedrooms� Lot Size sq.ft. Garbage Grinder(Aid) Other Type of Building 000A f'AA/11- No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Sr gallons per day. Calculated daily flow . gallons. Plan Date Zia" Number of sheets Revision Da Title 0 7Jd Size of Septic Tank iga Type of S.A.S. Description of Son; p /1-PA Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: . The undersign:sbe ees to ensure the construction and ce of the afore described on site sewage disposal system in accordance with thvisions of Title 5 of the End nmental de and to place the system in operation until a Certifi- cate of Compliance h ssu this Health Date Application Approve4y Date R A 3 0'- Application Disapproved for the following reasons Permit No. Date Issued L No. C `��/�7 'i"5 �v t, ' f '#�' �j� ., f?�"`,n Fee i?00 THE COMMONWEALTKOF MAS,SAC�I'.I SETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF.B,ARNS A E} MASSACHUSETTS 2pplicartion for �0igpo0ar¢*p.5temc Colhotruction Permit Application for a Permit to Construct(VRepair( )Upgrade( )Abandon( ) PComplete System ❑Individual Components Location Address or Lot No. iV A YFLv A:4 411/VF. Owner's Name,Address and Tel.No. 79 j Assessor's Map/Parcel � � V 14 L4 j19 V/b L 155-/ NO Ga oa Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. -/7 Lf7 ?y-9 36-~ `�"9�/5" Type of Building: Dwelling No.of Bedrooms Lot Size 33•ill sq.ft. Garbage Grinder(Alj) Other Type of Building 4W900 PAAlV- No.of Persons Showers( ) Cafeteria( ) Other Fixtures I Design Flow n, �, gallons per day. Calculated daily flow .5406, c�S gallons. Plan Date `Z h Number of sheets Revision,D,at ,, r` Title ,'L.YD )" Size of Septic Tank -,2 /��ry Type of S.A.S. Description of Soil �n it E/o,,#-9"6fili t Nature of Repah s,,or Alterations(Answer when applicable) f f Date last inspected:' Agreement: The undersigned agrees to ensure the construction and Iaiinfen, ce of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the En dr nmental C•1 and not to place the system in operation until a Certifi- cate of Compliance has bee 'Ti ued-b Whizof Health.Signe `a Date Application Approved,�y /"'' .�'� Date Application Disapproved for the following reasons Permit No. j� 1 Date Issued s r ' ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( V)Repaired( )Upgraded( ) Abandoned( )by Ili f l y at 30 1",T1r J WEie ® 5Tf 4V 1 ha been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the sys m w.ill1 function as designed. Date 11670� Inspector ny- (� No. r-S►�C ''t'"{ ------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS liopool 6potem Con5tructioitPermit Permission is hereby granted to Construct( ifRepair( )Upgrade( )Abandon( ) System located at ;;,d e- t-N D Sf Jl 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 ust be completed within three years of the dat(by thi s pe t. Date: 1 �� Approved f . TOWN OF BARNSTABLEav.Y_ 1 b LOCATION_ i}a �4I nwcer SEWAGE # VII,LAGESTP1�"6'i�f e I Ua ASSESSOR'S MAP & LOT O l f/ INSTALLER'S NAME&,PHONE NO. . DYV1 t1tnht Al ?a Z-7/77 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) W=A (size) NO.*OF BEDROOMS �C BUILDER OR OWNER-Cca�f �G v�Lt, c� R PERMITDATE: COMPLIANCE DATE: Separation Distance Between t : 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 Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by From'. of Dwelt; Ci Town of Barnstable Regulatory Services l = Thomas F.Geiler,Director iUm Public Health Division Thomas McKean,Director s 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 2 Designer: Installer:Address: Address: �� �� Address: On �/ ,� �2c� was issued a permit to install a 11 ( te) (installerYj septic system at:cc "W425V- ZA-) based on a design drawn by ,Z2 N Z41,� (address) �G dated T (designer) VZI certify that-the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical.relocation of any component of the septic system)but in accordance with State& Local Re ns. Plan revision or certified as built by designer to follow. c D AlIEL BRAMAN CIVIL No.32686C er's Signa °�o��Fc►sT������`` FSS/ONAL (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC EokALTH DWIS j0N. CERTIFICATE OF_COMPLIANCE WILL NOT,BE ISSUED .UNTIL BOTH THIS FO • AND AS-- EMT CARD ARE RECEIVED BY THE BARNS'TABLE P LIC SEALTH DIVISION. �IIANK_'YOU. Q Healtb/Septica)edper CffaS ;Oo Form Town of Barnstable P# bossy Department of Regulatory Services �t1e, Publicf,Health Division Date ' 200 Main Street;Hyannis MA 02601 BAMISTABM _ KAM ib19'A Scheduled tJ� 20Q3 Time D'!Po�^7 Fee Pd. /00.00 � Date Schedul �� , Soil wSuitabili y Assessment for Sewage Disposal .R Performed By: L Witnessed By: W.r >. .. ..., i !!m... .. :!: _,:.n::n.,!, .:!!.:.'a,m,c::•,,•a!!!a!J:..;_;.!n,,.:!-::.da'li:!xgnJ-!!a��;,i.'!s:a,'.!•'.uu:a YII'ih,!��'!'r'l`.�'!:;iE:;;yi;!ht:.o:I:.!.A;;;•i i�+i!!h�;,VIi.!11!II,I ,I..I,r!..•.,1i..!.,�':F!n:4h:I,. !,.aivti ii _ , hi:l !%'4,!• ... 1 Q1P:V i.7I: pIN f ._ . d' Location Address �0�������/��p I,/�,� �,q�/� Owner's Name �� Address Assessor's Map/Parcel: Engineer's Name NEW CONSTRUCTION REPAIR Telephone# e6[� 41a—�//3�0 Land Use Gl! Slopcs(%) Surface Stones /Y6�✓F Distances from: Open Water Body ZLL5: 0 ft Possible Wet Area f/ Ot7 ft Drinking Water Well,7,3Q2-Q_ft Drainage Way /✓on//..:_ ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) i v hive z B 30 Z93, /g ' Parent material(geologic)/�.�P)7'7-6 ;-—/�•�R/i✓ De th to Bedrock d7��i2 Depth to Groundwater: Standing Water in Hole: 11/On/e!, . Weeping from Pit Face A6^4 ' [ Estimated Seasonal High Groundwater - :._ ,...rn.!!:!•.....!4 vU'II!!:µ1'+."n.!,::1! .: :'�.:NnY.":'d"',! , 'nin.!�4�:,!, r.•.'L'!nll�'",inP'!ia am,Y:I�, ,!n,q!r!lill':'III!�ii!!i!ill'1:1!i!i d';;il!n;::p�� , —!:!, 'm,,.,!r:,!. .rmp.+err-::v:•RI I � - : .4. •it� .-:i'.. !y!I: .::.,r......I.!...e. .. .. „ !: !'r i! ! ::i!! _ti a ...�, 1 Method Used: Depth Observed standing in obs.hole: r in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment & Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ ..' .... .........._..:.._......:......:,,:::...,::::::::.,...,..:,::!::!:r:!!!::,_;p'!:r!;:a:r":,';:._,!+31;"!?:!i:!;!,r:`;i;,!;!.=.!e;i!n!:i!€15:,:!::;::.:,::,y ._ _ .. .. ...;..,::::..a:: �:....:•:-:...:r..:. ,...._...,.ne'e:!n::1=.::::: ,,.n{,...:r:v,.. .;,...; ,..,.�:!:..:.❑1,! .!!. .1.!., ....!,.....n...r.,,,.! ....I.,r......lM....:..w... f .� ,�; ...r_P� n........:,. ...:.. .;;..,,al.!.!..I :. ...I.. h!:1,;;::. •an:' '!'!I.at ::.:, ..,._ tr.................. .: !......:..a.li.,.,I..n.,:r..:,:,.I I+.,...,..,„.._•. � ur ter.... .:':.a:. n;,,.r.:,,::..;: ,.:i_Yc.,a-�!!{r.!!!I!�I:'i.l"!e.,.:,Ir:u:::........:. �,HJ4.II�,h!:r4ILI.,!m;i:�l::r.:+:-.......:...,.n..,:''I_�..:,.,...r,..,., .........................::......... Observation Time at 9" Hole# Depth of Perc — Time at 6" Start Pre-soak Time Q An .!S Time(9"016) End Pre-soak Rate Min.Mch �<"� Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back-----�-- Q:HEAL'I WWP/PERCFORM Lo Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. o 110 ERVATII 1! :HC L....:........::........ :.:.::.:.:::::. .::::::::::::.::.::.: Depth from Soil Horizon Soil Texture. Soil Color Soil Other Surface(in) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. y 71,4 _ . .: . .. ................................................ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. e ff Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % Flood Insurance Rate Man: ` Above 500 year flood boundary No_ Yes Within 500 year boundary Not, Yes Within 100 year flood boundary No_ Yes DgFth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervio s material exist in all areas observed throughout the area proposed for the soil absorptionsystem,? If not,what is the depth of naturally occurring pervious material? Certification 1 certify that on // _(date)I have passed the soil evaluator examination approved by the Department of Environmental Protection-and that the:above analysis was performed by me consistent with the required trai �eerfiseanVdex, . Xjidesctibedin3lGCMRl5.0l7. Signahire Date--7zy—/ZcLg - -7 203 499 077 US Postal Service 1 Receipt for Certified Mail 2Z No Insurance Coverage Provided. Do nAuse for Interna'o al Mail See re YR[se Se tt Post Office, ZIP Code Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee Ln rn Return Receipt Showing to Whom&Date Delivered Q Return Receipt Showing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees is f7 M Postmark or Date C a I MStick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return ' address leaving the receipt attached, and present the article at a post office service m A window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the Q) ` return address of the article,date,detach,and retain the receipt,and mail the article. �,•, If rn 3. If you want a return receipt,write the certified mail number and your name and address � i on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a i RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the addressee,endorse RESTRICTED DELIVERY on the front of the article. M 5. Enter fees for the services requested in the appropriate spaces on the front of this E receipt. It return receipt is requested,check the applicable blocks in item 1 of Form 3811. it 6. Save this receipt and present it if you make an inquiry. 102595-97-B-0145 a J� Z 203 499 0.47 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reApe Se &Num r �_' ' i�/ ice,Stat I Cod .Y r Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee N rn Return Receipt Showing to Whom&Date Delivered Retum Receipt Showing to Whom, Date,&Addressee's Address 0 TOTAL Postage&Fees $ Cq Postmark or Date Q 47 ' a Stick postage stamps to article to cover First-Class postage,certified mail fee,andN charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service a window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the Z return address of the article,date,detach,and retain the receipt,and mail the article. LO 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the O O addressee,endorse RESTRICTED DELIVERY on the front of the article. 5. Enter fees for the services requested in the appropriate spaces on the front of this E receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. u`8 6. Save this receipt and present it if you make an inquiry, 1 o25s5-s7-a-ot45 a v• �IHETpw� Town of Barnstable O� Department of Health, Safety, and Environmental Services RARNSrnst.e. MASS. i639. Public Health Division ♦0 ArED�`�A P.O. Box 534, Hyannis MA 02601 Office: 508-862-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health November 17, 1998 Judy Hasselbrack P.O. Box 221 West Hyannisport, MA 02672 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00 STATE SANITARY CODE II, MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE RENTAL ORDINANCE ARTICLE 51 The property owned by you located at 30 Mayflower Lane, Osterville, , was inspected on November 9, 1998 by Edward Barry, Health Inspector for the Town of Barnstable, because of a complaint. The following violations of 105 CMR 410.00, State Sanitary. Code II, Minimum Standards of Fitness for Human Habitation were observed: 410.500: Water was leaking through the roof. Caved ceilings observed. 410.602A: Debris observed on the ground. 410.602B: The dwelling was filled with trash,rubbish and other debris. You are directed to correct the above listed violations within twenty-one (21) days of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. PE ER OF THE BOARD OF HEALTH o as A. McKean Director of Public Health hassel/wp/q/Is The Town of Barnstable J I Iealth Department got l �wn.n i 367 Main Street, Hyannis, MA 02601 Office 508-790-6265 Cie-O., 71omu A. McKean FAX 50bgqAT�17S W ~ A, Director of Public Health D NOTICE TO ABATE VIOLATIONS OF_105 CHR 410.00,STATE SANITARY CUDE I1� MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION quo The property owned by you located at 4r& " 2� ii�`��a inspected on /� fir , 199br by,2� B,�,h`�J P Health Inspector for the Town of Barnstable, because of a complaint. The following violations of 105 CMR 410.00, State Sanitary Code II, Minimum Standards of Fitness for Human Habitation were observed: You are directed rrect --viola s with xentp- four (24) ho of rec of this ice. You are also directed to correct within-T"WeAlT- ��l 2 days/hours of receipt of this notice. You may request a hearing if written petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean Director of Public Health ` ,i , A G c ~� 12:30 1:00 :::::::::::::::::::::::::::::::::::::::::::::::::.:::.::::::::::::::::::::::::::::::::::::: 1:30 2:00 2:30 3:00 3:30 4:00 4:30 5:00 5:30 ' 6:00 10:26AM Friday, December 18,1998 First-Class Mail UNITED STATES POSTAL SERVICE Postage&Fees Paid USPS Permit No.G-10 o Print your name, address, and ZIP Code in this box C Public Healt DM8104 Town of Bamstabla PO.Box 534 aic,jls,Massachusetts 02601 i1�'.tFtllilt!11111114:!lS11-I�11'.!?�i�}'.!{1�!!�1[�ii��l tlitli'.11�:� d SENDER: ` o ■Complete items 1 and/or 2 for additional services. I also wish to receive the m ■Complete items 3,4a,and 4b. following services(for an d ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. 7- 0 Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address permit. $ ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery y ■The Return Receipt will show to whom the article was delivered and the date a C delivered. Consult postmaster for fee. 3. le Addressed to: 4a.Article Number d E E .Service Type r +' ❑ Registered Certified ¢ of ❑ Express Mail ❑ Insured a Uj c ❑ Return Receipt for Merchandise ❑ COD 7.Date of Delivery '\:Jla�, JV Z Y ...5.,Received B "I.Nel " ` 8.Add ssee's Add; ss(oni' if d and the is paid) /, H ' g 6Signatur (Addre ee orAgen Ps For'3811, December 1994 —Tbb -sr-,Pw79 -Domestic rn Receipt N N ! V N uj _ j J O cm _ OL � ' U Q J LOT G S f o 33417.3 5.f. O w _ Q f r ~�, INVERT OUT BUILDING'SEWER: EL. 31.2 O 4 c��S , ;s BUILDING LOCATION PLAN I�NveRT IN Jy�J FOR SEPTIC TANK: EL. 28.75 GOa ' 30 MAYFLOWER LN . , 05TERVI LLE, MA PREPARED FOR I DAV I D * 5UZAN N E L#55Y EXISTING SCALE: DATE: DRAWN BY: 5EFTIC ��N OF '. I " = 40' 05- 1 0-2007 TMW P `rd SYSTEM JOB NUMBER: REVISION: SHEET NUMBER: v 4= STEVEN W. tiN 04-OG I CPP-5 RUM e 3 ' WELLER A550CIATE5 Zvi � OFess�o`'PQ I G45 FALMOUTH RD., SUITE 4C P.O. BOX 4 17 CENTERVILLE, MA 02G32 2 WINDY WAY, #232 NANTUCKET, MA 025-54 TEL.: (508 �E���w , ``� �,� MAIL:-Otr swe{ler�,mcomcast.OBn �75-0754 �� .(7 PROFE55IONAL ENGINEERS LAND SURVEYORS f NN �. CV J Lo IU n V aL Cfl O N � a' V Q LOT G 8 J 33417.3 S.F. lu •�,s i ���tN OF MAssq ? STEVEN W tiN �% G'SToc.0 Ado E .c•�✓c� �, , 7 %% �QACFESS���OQ �`% 11 .01 PROPOSED �� �a '. POOL CABANA lip_ r 0 BUILDING LOCATION FLAN 15.0 lot, It FOR, 30 MAYFLOWER LN . 05TERV1 LLE, MA DK�.• ;' PREPARED FOR DAV I D 4- 5 UZAN N E LI 55Y 5CALf DATE: DRAWN BY: ' • V% OF MgsJ � � I " = 40' I 0-27-2000 TMW JOB NUMBER: 04-00 I REV15ION: 5HEET NUMBER: CPP-3 � T VEN 1N yc Z - Z7- v 7 `D MBA m 3 7 WELLER * ASSOCIATES I G45 FALMOUTH RD., SUITE 4C -•- P.O. BOX 417 CENTERVILLE, MA 02632 �G S'Uti�ry 2 WINDY WAY. #232 NANTUCKET, MA 02554 TEL.: (508) 775-0735 — FAX: (508) 775-0754 EMAIL: tnsweller(Scomcast.net PROFESSIONAL ENGINEERS t- LAND SURVEYORS oc .. r-.• .•-Y a•-Y 3'-Y-.. 11•-7 .II•-Y Y-W' -� �� oa aO C_> �-) HEAD PCC 249 rro .•all s i o I rp � R DECK � _� � � _ s7 3,4.66 ems• -GUiIES9�` ffiY U.O IT EC,T.L E) L BREAKFAST 2a�)21- 2� II 71W LVL f4`M f.�A PO!•T TO � ifi- oP-I�III � 3a STEM ENEAM FLIMM LAUN R7 � *L r w 3 ' 'L file (TILE) Es + r_ 3a 3 a + - PORCH a FAfILY ROOM NE -IIli 0 II ��IIlr--7\0IU a1�'T 0I\i Jll�-I 7.l,1I1 fa ''f LOgap^P101wO0 �° 2i (LEGACY PR8) KITCHEN MLEJ 2' i Y- • 12'-V 2' 3'-b' P-3• _- �At GOUAM --------- ------- �GARAGE r m+c stoe DRY (nLE) a'R P PORHs 71 PTO I I I I I I I n 2'� 24, W-0♦" �� i i i i I t I �� 5'�• - ` w LIVING ROOM(LEGACY PFNE) PORCH a �•_d ml I PTD 2q"-2 U 2dM FOYER rro h � '(t.►sacT PTA) 2a LLI - rL j z .a. Z PORCH a a 4 � 1 t!_t � T IO' r 10' r 1d S3 I6'-d 12'-01 2T-d i'-d 14'-d 26'-d FIRST FLOOR PLAN 544EET. &GALE: IIA' V-O' 11 t v 7 2e'-0' 4-0' Za-d 4'-0, N 1a 1M1 � N c ti a o PiD r161 C -- lit _ Df8 72pLt-Q� - Ill 72'KW' m i0 rn O rj � 0r jto I - A y + i y a �. PGG 7GCJ6-A � 3 q PCC r0A-A y - e7 N4'xAA 5/47A A/41x16 5/4' _ lo'-Id I I It 6 - - - O • rl 114'xAl1 A/4' ��, :.QOm To rong g ^A D - PtG.29641-3 67 N4'Ir51 5/41 . C a PTD 1'B1 I ® W 71 UAW A/4' N � 3'-i 1/4' PTO 21" 21 A/4461 A/4' 1 d 1 I k a ,. II'-II 3/4' 0' Q p 19'-6' JOB LOCATION R� 1.185Y RE ll�1SIDENCE o /moil 1I ll l�J 1J ll ll u 9. � C` ol��'IoGf l��'l �QMLa�3C y CGNT.ERIVOLL Cy MA O 6 31� PLAN lPfi 00U�IC,o 5006-STD 9 e 9 0d0 FAX- o BOO£377�I300.9 SIN 0 r Id I r------------------- tsrAwlr+cwlu. i I w FOUND. row - I #Ytaw I Q I FULL BASEMENT I CCROP NALL b e I I >x1L>ha m •. ra•nrr. /.rc. - I 1 L— / n — — -- -- - _— o f . 27 — ——————— I---------------------- Q P -- ---- --� g ----------- — � j afxl roacrr �' BeAr+P000<r rocpZT J ` 1 I I � r no o0 I q I PORCH o j I I anon a ano's b arlo', I I I •. I I aOPeMe I&FM oc+ort Ila I { I I m 1 m FULL b o _. j GARAGE i I s s I 1 I I PAD 9 c-CcCcur I a•CQIQtE1E SLAB I= { L—r—J - L 4 _ r—J.-. ______---_'____________ _i O { I I I r—e'er-a'cwc.wALL I f W.W cnr-r.wont+. i I I I I I BEAM 'cFT _ _ i D13-aese tw FOR coat P00=T —J L Ig AD sysim� r � "--n'carc-wAu -- _ { \ tNao•catr.FmTler. - - o ———— 1 -- ——— J ? I I I s-td I 1 -- ------- —————— ———————— I I1 1 IZda. I I •12'bL I 1 I 1 • I I � _ s I I � V 3_w ar rl o I I i Ii. I I Z 17-d CFy9 fl7�TL'T 1 I , ;p1�V Q L _---- ----- — — %i O ' J . .... -, . .- .. 4- _ Z --------- --------------- i a .. r r.— � � Q 1 CL PORCH 1 � . 'T-11'� T-II' T-11• b•-w � tVtnnl Y4 FOUNDATION PLAN SCALE: VA' P-a. �EET ---- - -— -------- - - - ---- -- - - --- _ --- _ --- --- _ - -- - - —-- - - - - --- --- - - - - -- PROff I LE- NO T TO Sr ALE TEST Ma-E LOG 2"LAYER OF 5/8"PEASTOPE DATE:DULY (7,2003 N P—I p53�} EL= ".5 FIRST PIPE UD46TH OVER'/A'-1 I/2"POUPLE rOP FOi�DATION COVERS T�) WITHIN TO M SET LEVEL WASFiF�STDI�E TEST 15Y: STETSON HALL,RS EL= %5f G• OF FIN07 GRADE FOR MIN. 2' WITNESS: SAM WHfFE,DARN.HLTH.DEPT. FINISH 6RADE PERC RATE: <2 MIN./IN. I t - 32.s +ram C- a. A" PV `/ �O q„ �,� wC TOP @ EL 288 O/A5 LOAM O/A LOAM n 5CH r :�Ica e sU acre g18 6" IN.5 9" I IN4fNJ 6V15DNTLL a COfrOM @ EL uloo p = LOAMY SW D - LOAMY SW 2 e 2.5 INOUMUTEE MST. 00 T W(FAI6 IOYRb/S f N Z000 6ALLaN 29.9 29" 9O�F 22" r 6.7 SEPARATION SEPf IC TANK 6" STOPS RASE DO<rCM OF TEST HOLE @ El_ 19.') W .HMO GI - �� SAW 27.2 61" 29.3 '3d II 62 = WM7 5A s �I Cl = 10 RARSE SW f i II 0/0 1 19.5 156' 22.E (ZO" I P NO WATER ENOOUNTERED i I 3q. o \ + DDs ION DATA \ DAILY FLOW: (5)BEDROOMS x 119 GPD=550 OPP \ SEPT 10 TANK: 550 GPD x200%= 1190 GPD \ USE: 2000 GALLON PRECAST SEPTIC TAN K LEACHING FACILfFY: `�• �\ / USE. (4) 500 GALLON PRECAST DRYWELLS LOT (0 LINED W/A' OF 120. 3LE WAS41EP STONE 5T. SIDEWALL: 110 x 2 x 0.7.4 = (628 OPP I POTTOM: 13 x 42 x 0.74 = 404.0 GPD TOTAL: 566 8 GPD � i 2 T.H. #1 32.9 3q GENERAL NOTES I CONTRACTOR TO M RESPONSIpLE FOR THE LOCATION OF ALL UTILfFIES, ABOVE AND UNDERGROUND,PRIOR TO ANY EXCAVATION OR CONSTRUCTION. 2. SEPT 1 C SYSTEM TO f3E INSTALLED IN COMPLIANCE W FH 310 CMR 15.00:TI TLE V 3. THIS PLAN S NOT TO f3E USED FOR PROPERTY LINE DETERMINATION h. ALL DI STURf5ED AREAS TO 15E LOAMED AND SEEDED 5. CONTRACTOR TO PROVIDE,48 HOUR NOTICE FOR ANY REgUIRED INSPECTIONS A \\ . TE �EVVAOE PLAN TAM = EL.345 \ \\\ 30 MAYFLOWEER LN., OSTERVIU E, MA OATOH �A51N RIM 'x x\ LOCAT1oN: <\ TN. �'� 3 PREPARED FOR: DAVID & SUZANNE LISSY SCALE: DRAWN f5Y: MIS q \ / TMW yi / ��`ZH of Mq 9 a ,,o�� DANIEL E. cyGN�, 1 \ \ BRAMAN JOp NUMf5ER: DATE. 07_U�—WO4 SHEET: T MB VV N o No 3IVIL N e 04-061 REVISED: 09-1�I--WO-4 I SP- �SSIONAI EaG\f WELL Aee061A TEeER t ;� �► 9-20 r0`- 1645 FALMOUFH FP - SUITE 46 OENTERVILLE, MA OUM TEL.: (508) 775-07-55 N FAX: (505) T75-0754 PROFE551ONAL ENGINEERS & LAND SURVEYORS