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HomeMy WebLinkAbout0046 MAYFLOWER LANE - Health 46 MAYFLOWER L'ANE:.° Osterville (FORMERLY:72 SYLVAN LN) N ; '1'40' 127 -,',! 2 `L ti1,1 n Commonwealth of Massachusetts �n Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 46 Mayflower L ; � Lane Property Address t David &Julie Gesner ; Owner Owner's Name t. information is , required for every Osterville MA 02655 09/30/2019 s 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: forms When fillip out f A. Inspector Information 9 on the computer, / use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 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 f 4. ❑ Fails 10-01-2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form '- `IQ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Mayflower Lane V� Property Address David &Julie Gesner Owner Owner's Name information is Osterville MA 02655 09/30/2019 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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 Commonwealth of Massachusetts ,� Title 5 Official Inspection Form Ala Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 46 Mayflower Lane Property Address David &Julie Gesner Owner Owner's Name information is required for every Osterville MA 02655 09/30/2019 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 46 Mayflower Lane Property Address David &Julie Gesner Owner Owner's Name information is required for every Osterville MA 02655 09/30/2019 page. Cityrrown 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 i Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Mayflower Lane Property Address David &Julie Gesner Owner Owner's Name information is required for every Osterville MA 02655 09/30/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems:(cont.) Yes No El ® 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 Y 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 0 the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ., y 46 Mayflower Lane � Property Address David &Julie Gesner Owner Owner's Name information is required for every Osterville MA 02655 09/30/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. " 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is of issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Mayflower Lane Property Address David &Julie Gesner Owner Owner's Name information is required for every Osterville MA 02655 09/30/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 550 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): GPD plus Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail In 1st half of 2019-20,000 gallons were used and in 2018-155,000 gallons and 2017-145,000 gallons were used. Records with water department are under 72 Sylvan Drive. Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 I ` Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .•, � 46 Mayflower Lane Property Address David &Julie Gesner Owner Owner's Name information is required for every Osterville MA 02655 09/30/2019 page. Cityrrown 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: 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form .1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .............. , 46 Mayflower Lane Property Address David &Julie Gesner Owner Owner's Name information is Osterville MA 02655 09/30/2019 required for every 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 8/21/2014 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 29"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): water was flushed during the inspection and it came freely. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form .1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Mayflower Lane Property Address David &Julie Gesner Owner Owner's Name information is required for every Osterville MA 02655 09/30/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): " Depth below grade: 20feet 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: Standard H-10 1000 gallon Sludge depth: 31- Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 21, 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 12" sludge judge How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of the inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L 46 Mayflower Lane Property Address David &Julie Gesner Owner Owner's Name information is required for every Osterville MA 02655 09/30/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts , Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Mayflower Lane V� Property Address David &Julie Gesner Owner Owner's Name information is required for every Osterville MA 02655 09/30/2019 page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont:) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover: 1 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Mayflower Lane Property Address David &Julie Gesner Owner Owner's Name requir required is Osterville MA 02655 09/30/2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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 i Commonwealth of Massachusetts Title 5 Official Inspection Form Flo Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Mayflower Lane Property Address David &Julie Gesner Owner Owner's Name information is required for every Osterville MA 02655 09/30/2019 page. City/Town 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.): At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Mayflower Lane Property Address David &Julie Gesner Owner Owner's Name information is required for every Osterville MA 02655 09/30/2019 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Mayflower Lane Property Address David &Julie Gesner Owner Owner's Name information is required for every Osterville MA 02655 09/30/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters. the building. Check one of the boxes below: ® hand-sketch in the area below - ❑ drawing attached separately Pe l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 M 1'�y Fla L-J v— TOWN OF BARNSTABLE LOCATION.. ~s SEWAGE# VILLAGE 0,P r ASSESSOR'S MAP&PARCEL, 4 0 INSTALLER'S NAME&PHONE NO. ���Ot`rGj� 3y S D>lJ7 SEPTIC TANK CAPACITY /ro© G.d 4 /*/,P LEACHING FACILITY:(type) NO.OF BEDROOMS S OWNER Cr1'ti csO'Z PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ra 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 yt a � - 9 y-y6 0 1 d Ris�o*row ia � � FR' _ n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 Mayflower Lane Property Address David &Julie Gesner Owner Owner's Name information is required for every Osterville MA 02655 09/30/2019 page. Cityrrown 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: 12 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: On permit filed with BOH 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 Commonwealth of Massachusetts Title 5 Official Inspection Form + Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 Mayflower Lane Property Address David &Julie Gesner Owner Owner's Name information is required for every Osterville MA 02655 09/30/2019 page. City/Town 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 t5inspAoc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE LOCATION �� �y����' Z"' SEWAGE VILLAGE ®J'T ASSESSOR'S MAP&PARCELA%'ol oT 7 oO� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ,,,e''4& LEACHING FACILITY: (type) C ep,a'CO-'Ie C114/*4 ze --"-T X taX;: NO. OF BEDROOMS OWNER 6C PERMITDATE: ��f9-i�' COMPLIANCE DATE: —°x�_�� 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 all, ON ® CN ® NO o � �. x C4 O� 'tea-.r• �' 1 Tb No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS \ Zipplitatlon for Misposal 6pstem Construction Permit A plicgpn fora ermit to Construct( Repair( ) Upgrade(Abandon( ) e Complete System ❑Individual Components Location Address or Lot No.,� fjJ�"?­ Owner's Name,Address,and Tel.No. Assessor's Map/Parcel��®,�.�7 Installer's Name,Address,and Tel.No. Designer's Name,Ad:ress,and Tel.No. ow Type of Building: Dwelling No.of Bedrooms Lot Size 1 sq.ft. Garbage Grinder( ) Other Type of Building `J No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date �� Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) J'<e' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued Boardef1jealth. e O , Q) Date Application Approved by / Date ' Application Disapproved b 27 Date for the following reasons Permit No. -- ,I Date Issued 91ZI No. Fee THE COMMONWEALTH OF MASSACHUSETTS THE in computer: "`PUBLIC HEALTH'DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes plication for Disposal 6pstem.. Construction permit pr p /Xon�?fb_r 1� 'f ' L (1 ' A licaa e i .to onstruct Repair( ) Upgrade(Abandon( ) !�Complete System ❑Individual Components Location Address or.Lot No. �� f jI�j��l.+ ./��7. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel�✓o/.Z 7 o o 4 G �9JJ'� Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building e/C Jp No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) � � gpd Design flow provided d`tS'�— gpd Plan Date :P —/�/y Number of sheets / Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil �*��e$' ��i3 ✓' Nature of Repairs or Alterations(Answer when applicable) .J'cc`d" Date last inspected: r, 1 Agreement: 1 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 bis -this Board ealth. gnd 0DateApplication Approved byMEWDate /Application Disapproved by Date for the following reasons 4 6, Permit No. Date Issued T THE COMMONWEALTH OF MASSACHUSETTS " '1 BARNSTABLE,MASSACHUSETTS Certificate of tompliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) AbandonedC( )by �! L' 44`G610 ce at �,x � y liA/s� � �✓ © f'T has been constructe oaccordance with the provisions of Title 5 and the for Disposal System Construction Permit No9fed Installer G G�/806`!//�- . ��✓� J'y C, Designer geO�is/,> 7�J� �!'�,✓ f; #bedrooms Approved design flow y*dta gpd The issuance of this permit shall not b const a i as a guarantee that the system w',I n,tion designed. q Date �� / / Inspector----- ---I--- ---- �t� - - - --f - - -. - -,-(J-----/-----/1--�-�" /I� ---- No. Fee frvTHE - COMMONWEALTH OF MASSACHUSETTS I PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 9ppstem Construction permit Permission is hereby granted to Construct( Repair( ) Upgrade( J-)" Abandon( ) System located at �/� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Consttructi,n must a completed within three years of the date of this permit. Date Approved by ) �- �V AUG/21/2014/THU 08:49 AM FAX No, P. 001 ' 'own of Barnstable F oa e� a Regulatory Services Richard V. Scali,Interim Diritor H1 MSTAstA YAn Public Health Division Thomas Mcxqn,Director 200.Main Street,Hyannis,NIA 02601 office: 508-862-4644 Pax: 508-790-6304 Installer&Desiper Certification.Form „ Date: �/ �f` Sewage Permtit �®�� �9�_Assessor's 1Map1I'arcel , Designer: d 7sta3ler: � . Address: � � Address: �. --��- was issued a permit to install a On - ,� ��.- � — � (instaL.ler) � septic system at �"i�t' 1 based on a design drawn by 'nA (address) dated (designer) I certify that the septic system-referenced above was installed substantially according to the desi�, which may include nunoz approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory, I certify that the septic system referenced above was installed with major changes (i.e. greaten than 10' lateral relocation of the SAS or any vertical relocation of azay component of the septic syst=) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out (if required) was inspected and the soils were found satisfactory, I certify that the system referenced above was constructed in com 'grace with.the terms of / the IIA approval letters (if applicable) D AVID taller' x % MASON hrr,I Na 1066 r; & o (D agner ignature} (Affix DesY p Here) PLEASE RETURN TO BARNSTABILE PUBLIC ]EEALTH DMSIDN. CERTIFICATE OF CONT IPLIANCE 'WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND A.S- BUMT CARD A ' t RECEIVED BY TEE BARNSTABLE PUBLIC BAIT D SI W. TIUNK YOU QASeptic\Designcr Certification Form Kiev 8-14-13.doc u oasr.um cma+ro �f .� roaauw oasr.00mc reneior.>ro. S r oasr,� roa�euw �, oas*.weonr ssrc_x+sar+uu. ro�cau� 6$$ ��srwm —r awcusmsrta�mr 2 oast.YE0000p 3.� JiCa>OEMOBINOfLT mner+w auras>+mwmnsaev 8� �!8 -_i_..r.0- - . �amassEw>suwaon+c f{S f S c+oo[Pos+osxsmsa��oersa+ I jjZ 13 EXIST 1ST FLOOR LAYOUT e s 8J i,a aese seas ( Xr urea my uss _ sxaossan � ®1 •,� , - +aessoom 6 Seale: 1/4'=IV Date: . w wzw n w rc 810 SET .J; 8-8-14 +• wua rnxs w,ui russr I+•aEe w.w PERhg1T SET 8-12-14 2ND FLOOR LAYOUT Page: 2 of 3 Town of Barnstable ' Department of Regulatory Services M Public Health Division Date 200 Main� Street,Hyannis MA 02601 APEU AAA'I A , r I . Date Scheduled 6 A 1q) Time /� - Fee Pd, i v Soil Suit 'lity Assessment for sew g Dis' osa Performed By: Witnessed By: m . I (LOCATION& G/ENERAL,INFORMATION k - Location AddressZ" 6 Owner's Name >> ®J/ Address Assessor's Map/Parcel:/�a✓.t .7 -;'0 Engineer's Name®.4ige 0,,W S0,t XP NEW CONSTRUCTION REPAIR. Telephone# Land Use \ Slopes(96) Surface Stones- Distances from: Open Water Body t Possible Wet Area ft Drinking Water Well ft Drainage Way tt Property Line ft Other ft n SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests;locate wetlands fn proximity to holes) iA Zow 1 . Patent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole:_ Weeping from Pli Race Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH[WATER TABL,F Method Used: Depth Observed standing in obs.hole: In. Depth to sell mottles: In, Depth to weeping from side of obs.hole.. In, Ground%vater Adjustment tt. Index Well# Reading Date: Index Well level Adj,factor m 4 Ad,{,Groundwater Level PERCOLATION TEST Date_,_ �„.'lYme,. , Observation _ I� Hole# _ r Time at h" Depth of Perc Time at 6" Start Pre-soak Time @ ,t sf111 Time(9"-6") End Pre-soak �1J� Rate Min./Inch LO Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back=---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:IS EPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil 'Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. onsi§tency.%Graven © ��✓ 1 I DEEP OBSERVATION HOLE LOG Dole# Depth from Soil Horizon Soil Texture Soil Color Soil Othe Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. CongisLency,% ra DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color ' Soil Other Surface(in.) (USDA) (Munsell) . ' Mottling (Structure,Stones,Boulders. Con i to c Gravel) r r DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. consistency. Flood Insurance Rate Mau: Above 500 year flood boundary No— es ✓____ Within 500 year boundary No es .r Within 100 year flood boundary No. Yes Depth of Naturally Occurring Pervious Material Does at least four feat of naturally occurring perviou a rial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth o nat rally occurring pervi 'u s material`t Certification I certify that on 10 (date)I have passed the soil evaluator examination approved by the Department of Environ ental Protection and that the above analysis was performe by a consi tent with . the required trai ' ,experti rid pe ien a described in 10 CMR 15.017. Signature Dana Q:\SEPTl0PERCFORM.DOC Commonwealth of Massachusetts ` v Title 5 Official Inspection ' Form Subsurface Sewage DisposAi.System,Form -Not for Voluntary Assessments M 72 Sylvan Lane Property Address Elleen Hickley Trust Owner Owners Name information is required for every Osterville f MA 02655 11/5/13 page. City/Town State Zip Code Date of.lnspection 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 filling out forms A. General Information on the computer, use only the tab key to move your 1. Inspector: cursor-do not James Ford IJI �I I use the return Name of Inspector key. f . Company Name 5 i P.O. Box 49 Company Address 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 E aluaiion by the Local Approving Authority 11/12/13 Inspe t is Signature II 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 qpd 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. t 1 qa - l5ins•3/13 9 Title 5 Offcial Inspe n m:Subsurface Sewage Disposal System-Page 1 of 17 1: , 1 k , Commonwealth of Massachusetts Title 5 Official.: Inspection Form Subsurface Sewage Disposal System form - Not for Voluntary Assessments 72 Sylvan Lane Property Address Elleen Hickley Trust ; Owner Owners Name information is required for every Osterville MA 02655 11/5/13 page. City/Town State Zip Code Date of Inspection B. Certification (Cont,-) Inspection Summary: Checks A,B,C,D or E/always complete all of Section D i A) System Passes: it y ® 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: I t; y , it 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 an`d over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substant'ial: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. z o *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): ; �i \ ti k 1: \ .1 1 t5ins•3/13 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 t1 Commonwealth of Massachusetts v Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Sylvan Lane Property Address Elleen Hickley Trust Owner Owners Name information is OSterVllle required for every ! MA 02655 11/5/13 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)afre,replaced ❑ Y. ❑ N ❑ ND (Explain below): ❑ obstruction is rei.noved ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N . ❑ ND (Explain below): 9 r. ❑ 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): , r y. 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: I'`a El 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 15ins•3/13 j Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 - Commonwealth of Massachusetts r , W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Sylvan Lane Property.Address Elleen Hickley Trust ;. Owner Owner's Name information is required for every Osterville MA 02655 11/5/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has allseptic 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 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 septia 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 indicatesl 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: �i i E 1' D) System Failure Criteria Applicable to All Systems: You must indicate"Yes' or"No"to each of the following for all inspections: Yes No ❑ ® Bac)up 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 oian 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I y. .. i Commonwealth of Massachusetts v Title 5 Official; Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !P y 72 Sylvan Lane Property Address Elleen Hickley Trust Owner Owner's Name information is required for every Osterville MA 02655 11/5/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.). Yes No t,. ❑ ® 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�lo�tion 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. ❑ Z Any'po'rtion 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 p ain of custody must be attached to this form.] b; ❑ ® 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 criteri.aekist 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 c®risidered a large system the system must serve a facility with a design flow of 10,000 gpo to:15,000 gpd. For large systems, you must in either"yes" or"no"to each of the following, in addition to the questions in Section D. t. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the ystem 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 G 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. !Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 r� j t. . f: Commonwealth of Mass°a;chusetts v Title 5 Officiell.. inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Sylvan Lane ; Property Address Eileen Hickley Trust i Owner Owner's Name information is required for every Osterville MA 02655 11/5/13 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 r . ® ❑ Pumping information was provided by the owner, occupant,or Board of Health s ❑ ® Were any.;pf 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 inspedtion? ® ❑ Were a�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? t ® ❑ Wereithe septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? El ® Was the facility owner(and occupants if different from owner) provided with informafoc, on the proper maintenance of subsurface sewage disposal systems? The s�ze 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)] , i D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310!CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 (Sins 3113 ! Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 - s F I i 'i 1 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Sylvan Lane r Property Address Elleen Hickley Trust Owner Owners Name information is 2. required for every Osterville i MA 02655 11/5/13 page. City/Town :; State Zip Code Date of Inspection D. System Information Description: I : Number of current resident's; 0 Does residence have a garbage grinder? El Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected?. El Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: unavailable . ;. Sump pump? ;`� El Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: a Design flow(based on 310'CMR 15.203): Gallons per day(gpd) Basis of design flow(seati7 PIP rsons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No .: Industrial waste holding tan,k,present? ❑ Yes [I No 4. , Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No Water meter readings, if available: t5ins•3/13t '% Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts v Title 5 Offici [ Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 72 Sylvan Lane ` a Property Address Elleen Hickley Trusti Owner Owners Name information is required for every Osterville " MA 02655 11/5/13 page. CitylTown i State Zip Code Date of Inspection D. System Informati6l (cont.) Last date of occupancy/use: : Date Other(describe below): } '7 General Information Pumping Records: i Source of information: } unknown Was system pumped as part;of the inspection? ® Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: maintenance Type of System: ® Septic tanli;;distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ' ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) { x ❑ 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 i Commonwealth of Massachusetts. i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not.for Voluntary Assessments 72 Sylvan Lane Property Address Elleen Hickley Trust Owner Owner's Name' information is required for every Osteryille _ MA 02655 11/5/13 page. City/Town i State Zip Code Date of Inspection Inspection System Information (Cont.) Approximate age.of all coM 'orients, date installed (if known)and source of information: installed-8/25/80-per as-built card Were sewage odors detected when arriving at the site'? 8 ❑ Yes ® No .Building Sewer(locate on site plan): T Depth below grade: feet . Material of construction . ❑ cast iron ® 40 PVC El 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 flan): Depth below grade: 16" feet Material of construction: d ® concrete ❑ metal ❑-fiber lass 9 . ❑ polyethylene ❑ other(explain) r I; r If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No • Dimensions: t, 1000 gals. Sludge depth: t5ins•3/13 + Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 • � i • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments' 72 Sylvan Lane Property Address Elleen Hickley Trust Owner Owners Name information is required for every OStervllle ( MA 02655 11/5/13 page. City/Town I State Zip Code Date of Inspection D. System Information (cont.) i Septic Tank (cont.). s Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 8" Distance from top of scum'lto top'of outlet tee or baffle, 6 ( Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? f Comments (on pumping r6c6mmendations,'inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The cement tees were present.There was no sign of leakage. The tank was pumped after the inspection. { r Grease Trap (locate on siteVplan) Depth below grade: feet f Material of construction ; k y, ❑ concrete ❑ metal , ❑fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: Scum thickness, Distance from top of scum!ltoi top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee_ or baffle. • Date of last pumping: h. Date t5ins•3/13 ' 1' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 A f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 72 Sylvan Lane Property Address Eileen Hickley Trust Owner Owners Name information is Osterville required for every MA 02655 11/5/13 page. CitylTown !; 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.): �i f e III Tight or Holding Tank(tank'must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: t ❑ concrete ❑ motal ❑fiberglass ❑ polyethylene El other(explain): N/a Dimensions: ,! Capacity: gallons Design Flow: i v" 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.): i. 6 Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No !I j t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official _ p For Subsurface Sewage Disposal System ystem Form - Not for Voluntary Assessments 72 Sylvan Lane i' Property Address Elleen Hickley Trust Owner Owner's Name information is required for every Osterville MA 02655 11/5/13 page. City/Town State ZipCode Date of Inspection D. System Information (cont.) Distribution Box(if prese'nt'must be opened locate o6sit( e plan): Depth of liquid level above.�outlet invert even Comments (note if box is IeVelarid distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The D- box was normal. ' , I it .1 l Pump Chamber(locate or;site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No' a Comments (note condition ' f,pump chamber, condition of pumps and appurtenances, etc.): N/a 4 i 9 ' y * If pumps or alarms are not.in,working order, system is a conditional pass. Soil Absorption System ($AS)(locate on site plan, excavation not required): If SAS not located, explain why: r , l5ins-3/13 p f Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 t; ..._.-__.... . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r G M 72 Sylvan Lane ; Property Address Elleen Hickley Trust Owner Owners Name information is required for every Osterville MA 02655 11/5/13 page. City[Town ? State Zip Code Date of Inspection D. System Information (cont.) Type: 1 - 1000 al. with ® leaching pits number: g - 1' stone ❑ leaching chambers number: ❑ leaching galle'rigs number: ii ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system 11 Type/name.of technology: Comments (note condition'of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pit had 6"of water on the bottom.There was no signs of failure. The cover was to grade. at fi ' 1 Cesspools (cesspool mus't 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, h Dimensions of cesspool i Materials of construction ' f Indication of groundwater inflow El Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 t Commonwealth of Mass'achusetts Title 5 Official' Inspection p n Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i °M a 72 Sylvan Lane Property Address v Elleen Hickley Trust Owner Owners Name information is j required for every Osterville MA 02655 11/5/13 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.): r :.• i, l,. Privy(locate on site plan):; Materials of construction: ,* Dimensions Depth of solids Comments (note condition of:I$oil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I N/a 1 4 t5ins-3/13 a' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I� i i • Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form- Not for Voluntary Assessments. 72 Sylvan Lane Property Address Elleen Hickley Trust Owner Owner's Name information is required for every Osterville MA 02655 11/5/13 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 9 t 8A��C I t 6 3 � p � sti6 a.o R. 3 S^9 )Lb jl 4 t5ins•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 X , ., 72 Sylvan Lane I` Property Address Eileen Hickley Trust s Owner Owners Name information is required for every Osterville MA 02655 11/5/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: t ❑ Check Slope ❑ Surface water f• ❑ Check cellar f. ❑ Shallow wells s 30' Estimated depth to high ground water: 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) I; ® Checked with local Board of Health - explain: Using topo and water contours maps ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USES database-explain: f You must describe how you established the high ground water elevation see above 1' 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 R' 1 R 1 i Commonwealth of Massachusetts A Title 5 Official,, Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ��H ,• 72 Sylvan Lane . Property Address Elleen Hickley Trust Owner Owners Name information is required for every Osterville c MA 02655 11/5/13 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 ,I S 0 l ; 1 � v S: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1 i LOCATION SEWAGE PERMIT NO. VILLAGE I N S T A LLER'S N;A,III E i ADDRESS OR OWNER DATE 0ER *If ISSUED �� .� ��f7 DATE C04APLIANCE ISSUED I i 1 Y� h No....... ` v , 0 _ G Fss..... ....THE COMMONWEALTH OF MASSACHUSETTS BOAR® HEALTH .............. ...............OF.................. ----............................................. Atip iration for BiovoM Works Tonitrnrtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair) ) an Individual Sewage Disposal System at r ............0.5t............. ......................................... c ion-Address or Lot No. - --- ..... ........ v.... .. =................................. wner ddress -- - - -- -- a �� -. ......... 1r • ..............�I s��,��✓ ........ .. ..---.................. Installer Address �- QType of Building Size ..........Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of-Buildin ............................ No. of persons.........1................ Showers / — Cafeteria a , Other'fixtures .......................................................... :f Design:flow........ X...........................gallons per person per day. Total daily flow.....r . ........................gallons. Septic Tank—Liquid capacityZP��•gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width...._....._. .._.. Total Length.....................Total leaching area....................sq. ft. Seepage Pit No......../_.......... Diameter..............X. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box 6 ) Dosing tank ( ) Percolation Test Results Performed bY......................<................................................... Date........................................ ►a � u tc�s .rggw- a Test Pit No. 1................minutes per inch Depth of Test Depth to ground water- ................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ •---........•--------------------------------------------------•---------•-•--...-•-----•--------•-.........-•---.....----............--•-•--•---•--------_.. Description of Soil <<� q/1..t�.-----I��``�•-•----...2..--•=-•.... F�G x W -------------------------------------------------------------------------------••-•------------------------------------------------------------------------------------------------•------------- 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 TL Ili LE 5 of the State Sanitary Code—The undersigned further agrees not to'place the system in operation until a Certificate of Compliance has been iss e by t bo of i lth. Signed---x . .... ... .... ..... ....... ..................... .......................... Date Application Approved By....... ..,. .....------•-•.....................•-••-•------••---..............._..---•- .................... Date.............. Application Disapproved for t e following reasons:....................................................................... ........................................ ---......-•-••.................•-------•--------•--...-------------•-----------------•-•-•-••-•-----.....------•--------------------------------•--•-------•---•-•---••---...••-•--......--------------- --- ............. JA-- e Permit No......... -----------------------•----........ Issued-•_ - $-` --- ------•---- Date V 4 No....... FEic........................... 10E COMMONWEAL CHUSETTS BOARD ILTH ................................OF.......................................................................................... Appliration for Uhipmal Works Tonstrurtion ramit Aoplicitibn is hereby made for a Permit to Construct or Repair an Individual Sewage b isposa System at: ... ...... ......................................... ........7-------------- ...........................7" A&A- P 'on-Address or t -------- ------------------....... .....caner dress ------- F .. . ....... ....... ...................... Installer Address Type of Building Size Lot__&I. feet Dwelling—No. of Bedrooms................................:...........Expansion. Attic Gartage Grinder 04 Other—Type of Building ............................ No. of persons........../---__------ Showers Cafeteria 04 Other fi tures .................................................................................................... Design Flow..._...__.4X............... , gallons per person per day. Total daily flow ;7 �[ '/-------- ..............................:1.............gallons. 9 Septic Tank—Liquid capacity....0.14940gaons , Length................ Width.._.._.......... Diameter................ Depth....._..._...._. Disposal Trench—No...................... Widths.....j�.r.... Total Length.................... Total leaching area....................sq. ft. T Seepage Pit No---------/----------- Diameter.................... Depth below inlet_....._............. Total leaching area..................sq. ft. Z Other Distribution box (A) Dosing tank 0 4 Percolation Test Resullf ,,Yegormed by-----------------------------------....................................... Date----------......--......---------------- A Test Pit No. 1.................minutes per inch Depth of Test Depth to ground water.._,."'__._----------- Test Pit No. .............minutes per inch Depth of Test Pit.__......._...._.... Depth,4,(Pground water.......___.........____. ..................­-----------------e...................... ---------­---------"---------- 0 Description of Soil.........1../*-[�191,/;;�� "I'll" mot`. .............. ........?��, / !, I ................................. ................................................................................. ...................."---------------------------------------- ........................................................ ------------ ------ ............................................................................................................................................ .......................................................... U Nature of Repairs or.Alterations—Answer.when applicable.................................:.............................................................. .............................................................. ................. ........ ............ ................................................................. Agreement: The undersigned agrees to install the af gec PrI�nd u �e e Disposal System in accordance with .4a r the provisions of i I V TeU gees not to place the system in until a Certificate of Compliance has or 0 th r operation ut� ben is �d b y e oa4rhea Signed.._.)................................... .............Date ApplicationApproved By------------ ............................................................................ ........................................ Date Application Disapproved for the following reasons_______________________________________________________ ............................... ._......._.... ...................................................................................................................................------------­---------------------------- Date PermitNo.......... ..................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................................OF....................................................................................... THIS�1Z ,QERTA;zAkt the Individual Sewage Disposal System constructed or Repaired by-_ --------- -------------------­------- ----------------- --------I-n-s-t, ----­------ ...... .......Y.Y.Z..;415C Il at......................................................................................................................................................................................................... has been installed in.la&ordance with the provisions of TIT L4.11.ef The State Sanitary Coe7a-,06scribed in the A. application for Disposal IV Permit ------------------------------------ .,I,qT.ks Construction P ,i 1�f 111.V.i d�ted................................................ "'i�;-,�15, THE ISSUANCE ,OF THIS CERTIFICATE SHALL NOT BE CO4NSTR D AS GU RANTEE THAT THE -SYSTEM W SATISFACTORY..,OLL FUNCTION ..................................... Inspector....... .. .. ...... ................ 4 THE COMMONWEALTH OF_MASSACHUSETTS V, BOARf W hLTH '69, ......................................OF..................................................................................... gel No........... .. ............... FEE........................ trudivit "pamit Permission;Wis hereby granted......................................................................;.......................................................................... to ConstructZ( ) or;Eiepair 4)�nyl9c4,Adu �q ,ge D pods 8 at No.---- -------------------------------. ........ -------------7-_T_7�;-------------­- as shofn-!p SppLicaV:afor,Disposal Works Co nstr t i�n' Permi t No.......... ..................................... ...................................................... ............................�T_,................. Board of Health.. DATE_ FORM 1255 HOSES & WARREN. INC:. PUBLISHERS _)OAA two REF-Ft c u CIE-E- k OCR IS AL_ 746'* 1 4 .4ee-4 't1spo�S&L T IT IV —7,Me.Lk/AL_1_ tr CE;D .fos=. 11-IROF TOTAL -t;,es,6K! .42c-;, 6--PT F:Lo v-1 - FL)- rZ&7-E: iQ i U' o rz 9 N, Iz Ul V Tor V'41> Loh,P4 A qG Box 1?6 c Sepric 114v. 7-A 1-4 VC w-if. 000 1w. 94, Z, Le-4a" A T f,-'T t 7- PLO-r L c>CATI O� a CA L L �o ',Aev Wc-4UIQGAA&"Ty Ds= T 14-To vi%-i or-- a AZ=lk7T, L4617 PAT C: I O�J)c Tt-Al Cli-4 4AJ IJ-X ('U_ 01,Uff-) Q-) "1`ilol Y . Ul O L .II + x � r ITp fv Tj iV c4to 17 i JFI a _ r F Y �1 f j� Lj :' t (�4 e hh �1 .- .. , la; PI wa AL l , i ASSESSORS MAP : - TEST HOLE LOGS �.. ' PARCEL : � _���, uard ul t) The installation shall con1i.;, with Title V and 'Town of9I�.Y,�o g . r S0 I L EVALUATOR: c�.� 1_1� I health Itegulations. G FLOOD ZONE: 2) The installer shall verify the location of ulililies, sewer inverts and septic ' � -- --- . _- --- - W I TNESS : -2)0 , REFERENCE: - zQ, components prior to installation and selling base elevations. C'�"`l�' DATE• / i ) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per li�ot.The first PERCOLATION RATE: . Z two leet out of the d-box to the leaching shall be level. 4) ;Phis plan is not to be utilized l'or property line determination nor any other T11- 1,�Z TH '6 purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. )4 l �.3 6) Parking shall not be constructed over 1110 septic components. c5 ' La 7) The property is bounded by property corners and property lines. Y'J ��` �( G �b 8) The property owner shall review design considerations to approve of total Z8� / �! � 8 design flow and number of bedrooms to be considered for design. Receipt LOCATION MAP of payment for the plan and installation based on the plan shall be deemed P??q,� {F� { ..hY}h approval of the design flow by the owner. j 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall bilk be removed along with contaminated soil and replaced with clean sand per - -- Title V specs. io � qq \ l �' L' .�(f, - ,q �► 1 10)System components to be 10 feet front water line. Sewer lines crossing the water line shall be sleeved with 4 inch SC1I 40 PVC with ends grouted if e o 3^ r l4zy applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as aforementioned and maintained in place. v i 11) If a garbage grinder exists it is to be removed and is the responsibility of the SEPTIC SYSTEM DESIGN owner to ensure such. mow` 1 12)The installer is to take caution in excavation around the gas line if such FLOW ESTIMATE 1 exists. l I 13)The installer shall verify the location, quantity and elevation of the sewer BEDROOMS AT/10 GAL/DAY/BEDROOM JR-_)GAL/DAY lines exiting the dwelling•prior to the installation. 14)'I'his plan is representative only that a system can fit on a property meeting SEPTIC TANK Title V requirements. c7J_0GAL/DAY x 2 DAYS USE /5 ?)GALLON SEPTIC TANK SOIL ABSORP I ON SYS EM�` Wow \ NZ, 1 Z MASON \ S`I DE AREA• X ' o y \ 0 p No.1060 a cry! - \ �'i BOTTOM AREA: lz� X 01 — GIs \ Z A � Y� � S-EPT IC SYSTEM SECT I ON L t L 7qf --- - (,�g7 �f�i ► ,2Qj LJ1 oC I'�V`r ri 1 b1 pi!D-Bg "" 4 vaL Z9,I D +Iwlpf101\ p SEPTIC TANK ou 1'a — I� 2oPy�s_Vtt�!L�vwlc , SITE AND SEWAGE PLAN u� i Ua� _ LOCATION bV44,,1 f PREPARED FOR : TiAA �,JpVY veV M O O ' SCALE: DAV I D 13 , MASON,I\5 DATE: DBC ENVIRONMENTAL DESIGNS EAST SANDWICH . MA Z DATE I HEALTH AGENT ( 508 ) 833- 2177 I � -- ------ - -