HomeMy WebLinkAbout0021 NATHANS WAY - Health 21 NATHAN'S WAY, OSTERVILLE
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TOWN OF BARNSTABLE nr�
LOCATION ` YJ,,-,\IA(XAS W r,,y SEWAGE# of 01 �_Oycl
VILLAGE �j \ � ASSESSOR'S MAP&PARCEL J a 6
INSTALLER'S NAME&PHONE NO. )C O k\ Vn Vr'c"rtA, .SU Y a 94 `1
SEPTIC TANK CAPACITY e A Sk l ow Ar_rya 0 fl�Q 64
`- LEACHING FACILITY.(typejO, 1k,% MO !,CV(,K%- S(size) N.S' )(0-N )4
',' NO.OF BEDROOMS
OWNER o 0
PERMIT DATE: r1 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private-Water Supply Welland 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
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Gar
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OCATIOM � SEWAC;E PERMIT UO.
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VILLAGE - - -- - - - -
I MSTA F� 5 Ali► � ADDRESS
BUILDER 5 Q &MF- AD I] E SS
DATE PERtvA1T ISSUED
DATE COMPLI h ACE ISSUED :
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No............. Fas..... .�f.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9f HEA H/
Apphratiutt -fur ltiipuuttt arks Tattitrurttutt Vrrutit
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
Sys� t A
............'2...... - ...... -� --------------------•---_...
c xocation- ss - or Lot No!"
Owner Address
1
G"
a .. - ---.... •-------------- --------------------- C�
Installer Address —1
U Type of Building Size Lot_.Z:15__��.���..Sq. feet
Dwelling—No. of Bedrooms-----------�..........................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
0.' Other fixtures --------------------•-----------
W Design Flow---------- 6)________________________gallons per person per day. Total daily flow................. .fir___ ._-._-_gallons.
WSeptic Tank—Liquid capacit/P4��allons Length---------------- Width................ Diameter-----........... Depth---._._-_-._..-
x Disposal Trench—No________________•___- W' 3._.__._____-_______. a ength______ �ota leaching area....�__C2_.Z.sq. ft.
Seepage Pit No.__ oa1 _. s t•h�et. et� cliin trea.. sq. ft.
g t 1
Z Other Distribution box ( ) Dosing tank ( ) C�s�" "��„ ���' ., 6
aPercolation Test Results Performed by........................................................... __ Date..........................-------------.
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water......__.__.-_.-_..__._-
L%, Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
----
�+ iL
x Description 01 Soil--------------40- - -- !'�.. _- i<L --------r �
V ----------- -----/ ._.---...�...�........................ .... . --•-------------------•---------------------------------------------•--•-•-----------
M _____________—_'___.._._._____.__-..-...-.--__--...__._...._._......._..__........................._..____....._....___________........____...__._______...._.____..________..___._...________..__..
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 Article XI of the State Sanitary Code—.The undersigned further agrees not'to place the system in
operation until a Certificate of Compliance has been issued by the board o ealth.
Sign 1 ��� -•---.�1 �r =
� � Date
Application Approved By-------=�!� -- •-_.....
�._...
Date
Application Disapproved for the following reasons:--------------------------
._.__ . —.... --•------------•-•........................... ---------•-_..
-------------------------------------------•-•------••-------_...._.....----------•----•---------•---•---I------------------------------------••---•-----------------------------------------------------
Date
PermitNo......................................------------------ Issued........................................................
Date
No.•-•-•-...........G.... FmE...... .J..........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEAL H,
-- OF......v� .fsi/... -'r..'7_._."�......................
Appliration -for e-i_qpuiitti or�k�Tomitrurtion Prrutit
Application is hereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal
System at,:
------_------ --- ---•--
e - /Location-Addri2s I of No.
i - Owner /r ell Address — r
f
Installer Address
d Type of Building Size Lot......................._..-.Sq. feet
U Dwelling—No. of Bedrooms------------P�-_---. .___.-___Expansion Attic ( ) tGarbage Grinder ( )
Other—Type of Building ----------------------_--_ No. of ersons..--_____--_____________-._pW-, yp g p _ Showers Cafeteria ( )
Q'' Other fixtures ............................... ..
W
Design Flow----------- _1�________________________gallons per person per day. Total daily flow----------------- __ __.d.-...__gallons.
U Septic Tank—Liquid ca pacity!G.�__ allons Length___-_____
t q 1` "g" ------- Width---------------- Diameter------.......... Deptit-------------
xDisposal Trench—No____________ ______ NV �•1�_____._.______.__T _al Length--------------------- leaching area.._.�.�L_�sq. ft.
Seepage Pit No....14?. �__ D- -r14et�ee&�.........P�el�i a _�eiT 44ea'ching area..-.-_----------sq. it.
Z Other Distribution box ( ) Dosing tank ( ) ��- / — �—G ` 7(f
aPercolation Test Results Performed bY---•---------------------------------------------------------------------- Date----•-------------------------------._..
a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water._..-.--..---.-..-.--_-
(� Test Pit No. 2____________ ___minutes per inch Depth of Test Pit.................... Depth to ground water------------.--._-_--__.
f, --•--- ---- I f -c -- --•-•---
`f /O
---
Description o Soil.--.-_- __._-Q t ( j
x
W
V 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the and o ealth. .
�- --"
Sine ... /. - .a f v.... _......-•----.... --•---------3-------------•-
/J Date
Application Approved BY---------•• =-(kd ------ ------ --:,---------------- ........ ' �-------
Date
Application Disapproved for the following reasons-----------------------•-•--•. .•. •-•-----•-•-•-•-••----------------•-•-•-------------- a.--..............
........................ ---•---------------•-------.---•--•-------------•-•.........._._......---------.................................................................... --------------•-• .......
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT)rI
0 F./
Tatifirate of f 111niViittttrr
THIS ISjQ CERTIFY, That the I ividual Sewage Disposal System constructed c e) or Repaired ( )
i�
ba_. ..-----
Y .._... << : '�
Installer /
at............. ...� ._..... ------------------------------------------
has been installed in accordance with the provision- _V1 e XI of The State Sanitary Cyced in the
application for Disposal Works Construction Per /r t No.(�_'1 le as described
__-_ _y�---------------- dated.... .....'. ....._._..._.....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A OUARAN E THAT THE
SYSTEM WILL FUNCTION SA TORY. ,,
,
DATE -- ----•------•...... Inspector....._
THE COMMONWEALTH OF MASSACHUSETTS
G BOARD OF HEALT
/ ....... .
�Gu�y�:........OF..../. .....--- ...........................
No. yL.--•. FEE........................
'�D
�i����tti � �rk,� ��a�t�tr rti�tt rrntit
Permission is here granted------.__ Lx
to Construcu�S ,r Repair an divi-dual Sewa�e Disposal System/ 7— ----------�- ------------`-�---�- "�-�`-/c��-----------------------•---
at No.. � �/ Street /
as shown on the application for Disposal Works Constructor P r it No ._ __ �r�}_ Dated-__. ._3."_7! ...............
Board of Health
DATE_
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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Town of Barnstable P#
.Department of Inspectional Services
. ' Public Health Division Date
z
AlEp Mp1 s 200 Main Street,Hyannis MA 02601
Office: 508-862-4644 N.j
Date Scheduled �`' Time �® Fee Pd.
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Soil.Suitability Assessment for ge Disposa
Performed By:_�� V Witnessed By:
LOCATION&rGENE INFORMATION
Location Address — c c c�,^5 Wc,y Owner's Name ( A 2 a 0
Address
Assessors Map/Parcel: Engineer's Name rCct Engineer's Email:
NEW CONSTRUCTION REPAIR V Telephone#.
Land Use Slopes(%) Surface Stones
Distances from: Open Water Body 10 t ft Possible Wet Area (0 + ft Drinking Water Well ���.r •ft
Drainage Way 10 t ft Property Line ` .1- ft Other' ft
i
SKETCH:(Street name,dimensions of lot,exact locations of tst holes&perc tests,locatewetlands in proximity to holes)
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Parent material(geologic) I"n roe i�Gl d` D� WC15 Depth to Bedrock 1 Pie-
Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASON{; S;,HIGHWATER TABLE} s,,
Method Used.
Depth Observed standing in obs.hole: in. Depth to soil mottles: 'Ac•i.e_ `d 134- in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level
Observation _
Hole# ( Time at 9"
Depth of Perc Time at 6" 14
Start Pre-soak Time @ -Gl� Time(9"-6'
End Pre-soak
2m '
Rate Min./Inch t 1
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y" .N
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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:Application Forms\PERCFORM 2018.doc
DEEP OBSERVATION HOLE LOG'
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
0 Qoo-j� CORM (0gK3/L JJo ]F6gllle'
e Loo,m Y 5c,o g 10 4-A 9 h le
07-34 9 Log.,y Sti1( (0qP, �/e Lov5e
�34 C t441 v S' Nq CD 1�R 614 tl Loose
i ,
DEEP.OBSERVATION°HOLE:LOG Hole# =Z
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
0-6� 0 Woop Low to g1z31,Z 1Jvvc� FrIto�E
4'7 E: Lokm Y S 1+Qn R t/11 11 •Fr, hie
`7 LooA� 4Q D I D KR- 41"//6 it . Fri'gb le
11t 34 5M [D Y -}f6 I' lose
DEEP'OBSERVATION HOLE-LOG ` Hole:'#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel) _
,a• i
DEEP OBSERVATION HOLE`LOG Hole# r
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel)
� I
Flood Insurance Rate Map:
Above 500 year flood boundary No_ Yes V
Within 500 year boundary No Yes
Within 100 year flood boundary No 7 Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring. ervious material exist in all areas observed throughout the area
proposed for the soil absorption system?- N-�
If not,what is the depth of naturally,occurring pervious material?
Certification i
I certify that on N a, 01� (date)I have passed the soil evaluator examination approved by the De yattm�"t o
Environmental Protection and that the above analysis was performed by me consistent with the req
expertise and experience described in 310 CMR 15.017. �o� DAVID oyG�
o D.
Signature ,.,. 7 Date �e�� �t 2,011 " COUGHANOWR
Q:\Application Forms\PERCFORM 2018.doc s < O
O /CENGE
/� FVAL&P
No. got?
Fee
7HE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
fltlritation for Misposaf 6pstem Construction Permit
Application for a Permit to Construct( ) Repair lam) Upgrade( ) Abandon( ) ❑Complete System individual Components
Location Address or Lot No. ` �� - , Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel I �.— I tsit„
Installer's Name,Address,and Tel.No. tC�} cA 'FV, D,gsigner's Name,Address,and Tel.Rio.
C..O, :_. (�d VV�vtd �6.,�1•.ti,.,,.�f jc
Type of Building: �� lei q b 0 Ij ' $`v Y 3�y t�f'[f
r '1
Dwelling No.of Bedrooms Lot Sizesq.ft. Garbage Grinder(W)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 2L c)c gpd Design flow provided 310 o- 6�4 gpd
Plan Date 2L \ ®C Number of sheets 1 Revision Date
Title
Size of Septic Tank t)4,'p,A %00b Type of S.A.S. 3 , Q Cj1
Description of Soil Tyl e Ie I � ►�.� � �;
Nature of Repairs
or Alterations(Answer when applicable)
4A �U � )��ii �" kA l
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. j G
Signed Date
Application Approved by Date ?j_ I J
Application Disapproved by 1 Date
for the following reasons
Permit No. ;2 V / o 5 Date Issued
Fee
7HE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for Disposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair(✓) Upgrade( ) pandon( ) ❑Complete System ®'Individual Components x
Location Address or Lot No. mE
rs Name,Address,and Tel.No.
�, e �w�� way Assessor's Map/Parcel Installer's Name,Address,and Tel.No. er's Name,Address,and Tel.No.
Co� M Fl�KaUtd Cov�lnrv,.V,'� c6 lr�
Type of Building: TO t{ V,q
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( (�
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Desigu'Flow.(r•.pin.required) -1 (� gpd Design flow provided 31n ,A%-, gpd
Plan Date: Number of sheets 1 Revision Date
Title
Size of Septic Tank t y i S,. %nb Type of S.A.S. r5
— v---� �
Description of Soil_M o 3&4,j i CS x -LY{?ce;>
Nature of Repairs or Alterations(Answer when applicable) (k_o „ e rj 0 �T�����` ► p ` `N
Date last inspected:
Agreement: ,<
r�.
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 th&Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date 7 1 l sb i
Application Approved by 1 Date �2-1
Application Disapproved by Date �—
for the following-reasons
Permit No. , O l / - 5 Date Issued - !?- f
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( )
Abandoned( )by S c�OJA en
at has been constructed in accordance
with the provisions`C1oft Title 5 and the for Disposal System Construction Permit No.eVol9-01 dated �t -13- '7
Installer S(:O n Designer
#bedrooms Approved design flow `� gpd
The issuance o this permit shall not be construed as a guarantee that the syste function as designed.
Date !i Ins
------------ ----------------------- ---- ----------- ------ --
-
No. �6 I G'f -- 6 5 _ Fee [ "�✓
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal :Fppstem Construction Permit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at t C- CAA S (NJ CL/ 0 S ir,,Py o a
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
c
Date Approved by
f
X Town of Barnstable,
egulatory.Services
Richiird V.S60,I:ntcrim Director
rt. 4
• PA.R L
Fu> li ai t }iviston
Th tnas mcK&au� Direddr
*Alain Street, I.y#uniS,.i�IA a2,tx01
Office: 508-862-4644. Fax; 5.08--790-064:;
Instalter& Designer Cerfificat do Form
Date: a 1 S'ewage Perm.jt# C1—On Assessor's aipTarcet
Pesi ner: C o eel .
.Address., Ys`? ��1„ Address.>
COA s V-� vas iss:eei a pern1it tt:Install:
(elate) (installer);:
septic system at 21 Nathans Way basodlon a�dcsiga d awn by
(address)
David D. Coughanowr,.RS dated Feb 11, 2019
(designer.)
I ceafiify th�it the septtc system--refereticedf above was ztstalletl scibstantially according td
the destga, which ma n%ncir approved eliattges surd; as lat'cral rcldc^atiori of-the
dioribudmi box and/or;septic; tank. Strip out; (if regiured} HJas ititipected.gild tl e:sbiIs
were found;satisfactary,,
l certify that dic septc system nabove was nl ansled � xthg (tc'.
greatern hfthe SASor any, relca oatirt tit any coin
portent
of the septic syOditi).but in accordance pith State&t vc l Rt vl"atidris. p146 revision'...
certified ms builtby'`dcsigner to fallow. Stripo it (if r tluired}'eras. t specteci and the soils
were found satisfactory"
f,certify tl ah the.,systein-refereneed above was:eonstructed i'm compliance with the terms
of the 1�.A`approval letters(if appl%cable} � .
*ii of F eF A
UAVI0 CIAVIO r'
ns allers e. fj
i oubH 0 , COUGHANOINR
IN
[} Leh 1
(Dcsigneras Signatures ner'a Staff
PLEASE RETURN TO BARN TABLE PUBLIC HEALTH:DI'VISION. .CER'I'IFICATE
OF COMPLIANCE WI'LL...:NW BE ISSUED UNTIL BMW'PHIS ORM. AND A&-
BU[i;T CARD ARE RECEIVED BY THE BARNSTABLE PUBLICHEAUTH Y-ISION
THANK YOU;
Q;4Sc06 esignerCcriifiouo.t Non Rev 8 14-13.46c:
ti
a
i -
58
AREA = 15092 sf+—
/ S
LAND COUP Pt.aN 32225—B \
MINIMAL ^,SSR MAP 122 Pcl 66
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PROPOSED
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Al = 21.7
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�t
M-DCertified Mail Fee t'C[p
$ rW
Extra Services&Fees(check box,add fee as appropriate)
❑Return Receipt(hardoopy) $ C S
E:3 ❑Retum Receipt(electronic) $ 1 r p06afk,'
O ❑Certified MaiLRestdcteC Delivery $_ t{efe
0 []Adult Signature Required $
[]Adult Signature Restricted Delivery$.
O Postage LL ---
m
Total Postage and —
�"BOOTH,TIMOTHY S&KELSEY E
m $
Sent To - - - 21 NATHANS WAY
C3 StieeiandApC"l�oa�
OSTERVILLE, MA 02655 ______
_ � Y
airy State;ZIP+4e-�
r r r �r rrr•r.
Certified Mail service provides the following benefits:
■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail
■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate
■Electronic verification of delivery or attempted return receipt for no additional fee,present this J
delivery. USPS®-postmarked Certified Mail receipt to the,
■A record of delivery(including the recipients retail associate. _
signature)that is retained by the Postal Service'" Restricted delivery service,which provides
for a specified period. delivery to the addressee specified by name,or
to the addressee's authorized agent
Important Reminders. Adult signature service,which requires the y a
■You may purchase Certified Mill service with signee to be at least 21 years of age(not A
First-Class Mail®,Rrst-Class Package Service®, available at retail).
or Priority Mail®service. Adult signature restricted delivery service,which
■Certified Mail service is notavailable for requires the signee to be at least 21 years of age
International mail. and provides delivery to the addressee specified
r Insurance coverage is notavailable for purchase by name,or to the addressee's authorized agent
with Certified Mail service.However,the purchase (not available at retail). L
of Certified Mail service does not change the Y To ensure that your Certified Mail receipt is
Insurance coverage automatically included with accepted as legal proof of mailing,it should bear a
certain Priority Mail items. USPS postmark.If you would like a postmark on
•For an additional fee,and with a proper this Certified Mail receipt,please present your =
endorsement on the mailpiece,you may request Certified Mail item at a Post Office'for
the following services: postmarking.If you don't need a postmark on this
-Return receipt service,which provides a record - Certified Mail receipt,detach the barcoded portion
of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply r-
You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.
electronic version.For a hardcopy return receipt,
complete PS Form 3811,Domestic Return
Receipt attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records.
PS Forth 3800,April 2015(Reverse)PSN 7530-02-000.9047
■ Complete items 1,2,and 3. gj
■ P,int your name and address on the reverse ❑Agent
so that we cart return the card to you. ❑Addressee
■ Attach this card to the barK. of the mailpiece, Received by(Printed Name) C. It3qf Delivery
or on the front if space perfiits. ��
D. Is delivery address different from item 1? ❑Yes
-- — If YES,enter delivery address below: ❑ No
:_BOOTH, T iI TH- SA fCELSEY E
21`WTHANS*AY
-'OSTERVILLE, MA 02655
_ I
II 9III9I IIII I9I I II Iles III I I II9II I II l0lll II III Service Type ❑Priority Mail Express®
EJ
❑Adult Signature ❑Registered MaiIT"'
❑Adult Signature Restricted Delivery ❑Registered Mail Restricted
9590 9402 4798 8344 8734 90 ertified MaIIO Delivery
Certified Marl Restricted Delivery OReturn Receipt for
❑Collect on Delivery Merchandise
2. Article Number(Transfer from service label) ❑Collect on Delivery Restricted Delivery ❑Signature ConfirmationTM
❑Insure,-""u l ❑Signature Confirmation
❑Ins:,'-' I Restricted Delivery Restricted Delivery
PS For stic Return Receipt
USPS TRACK NG#
First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10
9590 9402 49 344 8734 90
United States •Sender:Please print your name,address,and ZIP+4®in this box*
Postal Service
�� ;;��, Town of Barnstable
(/(k Health Division
200 Main Street
Hyannis,MA 02601
I I I
f
Vpm Town of Barnstable Barnstable
Oftwc
Inspectional Servicesac '
BARNf3TaBLF, x r
Public Health Division
y639. 1rb
pry°�APY s 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas A'McKean,CHO
FAX: 508-790-6304
CERTIFIED MAIL#7015 1730 0001 4987 9460
February 6, 2019
BOOTH, TIMOTHY S &KELSEY E
21 NATHANS WAY
OSTERVILLE, MA 02655
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 21 Nathans Way, Osterville, MA was inspected on
01/16/2019 by Sean M. Jones, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Title V septic system fails due to inadequate available leaching. There is less
than 6" in SAS, and less than half(1/2) days flow.
You are ordered to repair or replace the septic system within one (1) year from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF TH OARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health.
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\21 Nathans Way Osterville.doc
• r
Town of Barnstable
a r
+ 3ARN8fABIE. •
1' , ' Regulatory Services,Department
F—blicH—IthDivision ea
200 Main Street,-Hyannis MA 02601
Office: 508-8624644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 5/11/16
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1)YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool,or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO(2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
❑ // 1
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r;;
21 Nathans Way �?
Property Address '
4
Timothy& Kelsey Booth
Owner Owner's Name f
information is
required for every Osteryille ✓ Ma 02655 1/16/2019 °
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 Sly# 13 50a'
filling out forms
on the computer,
use only the tab Sean M. Jones
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection
use the return Company Name
key.
74 Beldan Lane
Company Address
Centerville Ma 02632
City/Town State Zip Code
508-658-3456, 774-248-4850 SI 4522
sean@smjonestitle5.com 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
1/16/2019
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
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owners Name
information is required for every Osterville Ma 02655 1/16/2019
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:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owner's Name
information is Osterville Ma 02655 1/16/2019
required for every
page. Cityrrown 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
'- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owner's Name
information is required for every Osterville Ma 02655 1/16/2019
page. City/Town 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
Title 5 Official Inspection Form
aI e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owner's Name
information is required for every Osterville Ma 02655 1/16/2019
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 Y2 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 CM 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
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owner's Name
information is required for every Osterville Ma 02655 1/16/2019
page. Citylrown 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?
® El available
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?
® F-1 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)]
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
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owner's Name
information is required for every Osterville Ma 02655 1/16/2019
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd
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:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owner's Name
information is required for every Osterville Ma 02655 1/16/2019
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:
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
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owner's Name
information is required for every Osterville Ma 02655 1/16/2019
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 Tto be obtained from system owner)and a copy-of latest
inspection of the I/A system operator
b system o e ato under contract
P Y Y Y P
❑ Tight tank. Attach a copy of the DEP approval.
® Other(describe):
septic tank and precast leach pit
Approximate age of all components, date installed (if known) and source of information:
original system 1977
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2
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.):
Joints ok, no leaks or blockages. Vented through roof
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface`Sewage'Disposal System"Form -'Notfor'Voluntary Assessments
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owner's Name
information is required for every Osterville Ma 02655 1/16/2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 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:
1000 gallons
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? measurements not taken
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Water level was even with outlet, tank appeared to be structurally sound, outlet baffle has rotted off
exposing outlet pipe.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
I�
Commonwealth of Massachusetts
l Title 5 Official Inspection Form
C. Subsurface Sewage Disposal System Form - Not for`Voluntary Assessments
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owner's Name
information is required for every Osterville Ma 02655 1/16/2019
page. Cityrrown 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
iiI Subsurface Sewage Disposal System Form -Not for'Voluntary Assessments
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owners Name
information is required for every Osteryille Ma 02655 1/16/2019
page. City/Town 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 N/A
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for"Voluntary Assessments
4 u
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owner's Name
information is required for every Osterville Ma 02655 1/16/2019
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: 1
❑ leaching chambers number:
❑ 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
Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form Not forl%oluntary Assessments
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owner's Name
information is required for every Osteryille Ma 02655 1/16/2019
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.):
leach pit was video inspected and was found wit standing water level 3" below inlet pipe. System fails
inspection due to inadequate available leaching.
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for`Voluntary Assessments
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owners Name
information is required for every Osterville Ma 02655 1/16/2019
page. City/Town 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.ow-rev.<7X28/2D18. Title 5 Official Inspection Form:Subsurf=e Sewage.0isposal System•.Page 15.of 18.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -'Not forVoluntary Assessments
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owner's Name
information is required for every Osteryille Ma 02655 1/16/2019
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
I ��v
v " o
O �
2
All 276
►.J 1 L-i 6
AZ tb
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
c®, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for'Voluntary Assessments
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owner's Name
information is Osterville Ma 02655 1/16/2019
required for every
page. CitylTown 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: 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:
Groundwater elevation was not established.
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
it
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- 11. Subsurface Sewage Disposal System Form -'Not for'Voluntary Assessments
21 Nathans Way
Property Address
Timothy& Kelsey Booth
Owner Owner's Name
information is required for every Osterville Ma 02655 1/16/2019
page. Cityrrown 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 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
t
4
Commonwealth of Massachusetts '
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 21 Nathan's Way
Property Address
Ingraham
Owners Name
Osterville MA 02665 6/11/12
City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms maymot be altered in any
way. `
A. General Information
1. Inspector: 4
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536.
Cityrrown State Zip Code
508.272.6433 ,
Telephone 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 Evaluation-by the Local Approving Authority
L 6/11/12
Inspecto Signat Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the 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. ,
Commonwealth of Massachusetts'
Title 5 Official inspection Form -
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
GSM
21 Nathan's Way 4
Property Address
Ingraham
Owner's Name +
Osterville MA 02655 6/11/12 f
City/Town State ` Zip Code Date of Inspection
B. Certification (cont.) -
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
- E
Pumping suggested every 3 yrs to prolong the life of the system '
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be.
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass. "
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. if"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is ,
structurally unsound, exhibits substantial infiltration or exfiitration 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.
s •
ND Explain:
n/a
❑ 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):
p'
❑ broken pipe(s)are replaced
❑ obstruction is removed `
Commonwealth of Massachusetts
Title 5 Official Inspection Form ,
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments.
�M 21 Nathan's Way
Property Address ,
Ingraham
Owner's Name z
Osterville MA . - 02655 6/11/12
Cityrrown State Zip Code Date of Inspection
B. Certification (cont..)
B) System Conditionally Passes(cont.): :
❑ distribution,box is leveled or replaced
ND Explain: - ;f
n/a
❑ The system required pumping-more than 4 times a year due tobrokeri or obstructed pipe(s). The
-system will pass inspection if(with approval of the Board of Health):
El broken pipe(s)are replaced
❑ obstruction is removed _
ND Explain:
n/a
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of.Health in order to_..determine if
the system is failing to protect public health; safety or the environment.''
1. System will pass unless Board-of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment: ;
❑ Cesspool or privy is within 50 feet of a surface water _
❑ Cesspool or`privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
' determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has aseptic 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.
Commonwealth of Massachusetts `
Title 5 Official Inspection Form `
Subsurface Sewage Disposal System Form Not for Voluntary Assessments r
,M 21 Nathan's Way '
Property Address .
Ingraham
Owner's Name
Osterville MA 02655 6/11/12
Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required,by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**. -
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria 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:
n/a
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"'or"No"to each of the following for all inspections:
Yes No _
}
❑ ® Backup of sewage into facility or system component due to.overloaded or
clogged SAS or cesspool `
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or'available volume is less
. �Z than '/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.
El Any portion of cesspool or privy is within 100 feet of a surface water supply or
® tributary to a surface water supply.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 21 Nathan's Way
Property Address
Ingraham
Owner's Name
Osterville MA 02655 6/1.1/12
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.) A
D) System Failure Criteria Applicable to All Systems(cont.):
Yes No `
❑ ® 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
❑ ® Any portion of a cesspool or'privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd. t
❑ ® The system falls. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be,.
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with"a
design flow of 10,000 gpd to 15,000 gpd.
z
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
• ❑ the system is within 200 feet of a tributary-to a surface drinking water supply
El El Area
system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area-IWPA) or a mapped Zone Il of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
wM 21 Nathan's Way
Property Address
Ingraham
Owner's Name
Osterville MA 02655 6/11/12-
City/Town State Zip Code Date of Inspection '
C. Checklist
Check if the following have been done.You must indicate"yes" or"no"as to each of the following:
Yes No ,
® ❑" Pumping information was provided by the owner, occupant,,_or,Board of,Health
❑ ®, Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous twoweek 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) _
Z ❑ 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.
® ElDetermined 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 21 Nathan's Way
Property Address
Ingraham " •-
Owner's Name
Osterville MA 02655 " 6/11/12
Cityrrown State Zip Code Date of Inspection ,-
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): n/a Number of bedrooms(actual): 2
DESIGN flow based on 310,CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
0 -
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes -® No
Water meter readings, if available(last 2 years usage(gpd));
Sump pump? ❑ Yes ® No
Last date of occupancy: , Vacant 2 months
` Date
Commercial/Industrial Flow Conditions:
Type of Establishment: . n/a
Design flow(based on 310 CMR 15.203): Gallons per day(9pd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non=sanitary waste discharged to the Title 5 system?. ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
n/a
Other(describe):
e
Commonwealth of Massachusetts
Title 5 Official Inspection Form .
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 21 Nathan's Way
Property Address Y .
Ingraham
Owner's Name
Osterville MA 02655 6/11/12, _ s
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
- General Information
Pumping Records:
Source of information: No history given
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: - '
r gallons
How was quantity pumped determined?
S
Reason for pumping: „
Type of System: -. .,
® Septic tank, distribution box,soil absorption system
i
n
❑ Single cesspool
Overflow cesspool i
❑ 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
1 inspection of the I/A system by system operator under contract- .
❑ Tight tank. Attach a copy of the DEP approval:
Ell 'Other(describe):" W
No D-Box
Approximate age of all components, date installed (if known)and source of information:
1976 per age of home'
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Commonwealth of Massachusetts
S
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4M 21 Nathan's Way • - . • ' -
Property Address
y•
Ingraham
Owner's Name
Osterville MA 02655 6/11/12
Cityrrown State • Zip Code Date of Inspection
D. System Information (cont.) '
k1
Building Sewer(locate on site plan): ;
18„ ,
c
Depth below grade:
feet -
Material of construction: '
❑ cast iron k ®40 PVC ❑ other(explain): . -
Distance from private water supply well or suction line- feet
Comments(on condition of joints, venting, evidence of leakage, etc.): '
Septic Tank(locate on,site plan):
Depth below grade: `
feet
Material of construction: -0 ;
® concrete ❑ metal' ❑ fiberglass ❑ polyethylene ❑ other(explain)
No outlet T
If tank is metal, list age: ^` ' "a years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ =Yes ❑ No
--------------------------------------------------- ----- ----,;------------------------------------------------_---
Dimensions: , 1000g
Sludge depth:' 3 .
Distance from top of sludge to bottom of outlet tee or baffle
>12"
' Scum thickness
d r' trace-1`' M.
Distance from top ofi scum to top of outlet tee or baffle >2
'Distance from bottom of scum to bottom of outlet tee or baffle
• measured
How were dimensions determined?
Commonwealth of Massachusetts '
Title 5 Official Inspection Form '
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 21 Nathan's Way ..
Property Address
Ingraham
Owners Name
Osterville MA ' 02655 6/11/12
Cityrrown 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.):
Pumping suggested every 3 yes to prolong the life of the system
Grease Trap(locate on site plan): ;r
Depth below grade: '
feet a
Material of construction: ,
❑ concrete ❑ metal ❑ fiberglass 0 polyethylene ❑ other(explain):
n/a
Dimensions:
Scum thickness _ 1
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: Bate
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.)
s
Tight or'Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete. ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
n/a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
21 Nathan's Way k
Property Address
Ingraham
Owner's Name s _
Osterville MA' 02655 6/11/12
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions: -
Capacity: r. gallons '
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No r
y
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
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
No D-Box
a
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: El -Yes ❑ No ,
IIII ,�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '
�M 21 Nathan's Way ;
Property Address
Ingraham '
Owner's Name
Osterville MA 02655 :6/11/12
Cityrrown State Zip Code- Date of Inspection .
D. System Information (cont.)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
n/a.
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
e
Type:
® leaching pits number: 1 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:'
❑ overflow cesspool number:
❑ innovative/alternative system
.. 4
Type/name of technology:
Comments(note condition_of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach Pit 3' below grade, dry at this time, stain line at 1/2 full mark, no indication of backup
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
W
M SVB'e 21 Nathan's Way
Property Address
Ingraham
Owner's Name
Osterville MA 02655 6/11/12
Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
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
t r
Comments(note condition of:soil; signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan): a
Materials of construction:
Dimensions
ro
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
n/a i
• Commonwealth of Massachusetts ;
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments'
r
M s. 21 Nathan's Way
Property Address
Ingraham
Owner's Name
Osterville MA 02655 6/11/12
Citylrown 'State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal'system including ties
to'at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
8ID 6z
e A
t
4 y
Commonwealth of Massachusetts
Title 5 Official Inspection Form - -
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 21 Nathan's Way
Property Address
Ingraham
Owner's Name
Osterville MA 02655 ' '6/11/12
City/Town State ' Zip Code Date of Inspection
1
D. System Information (cont:)
Site Exam:
❑ Check Slope
❑ Surface water :.
k
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: ,yF >12
feet
Please indicate all methods used to determine th6 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'150lfeet of SAS) w
❑ Checked with local Board of Health'-explain:
❑ Checked with local excavators, installers=(attach documentation)
❑ Accessed USGS database-explain:. `
You mustdescribe how you established the high ground water elevation:
per elevation of home
r
RECE'tl�D
Commonwealth of Massachusetts J U L 1 1 1996
Executive Office of Environmental Affairs HEALTH Dc �,
Department of ?OWN OFBARNQ- ABLE
Environmental Protection
William F.Weld Trudy Coxe
Ciowmor sec*wy
Argso Paul Celluccl David B.Struhs
u.Coarnor CommhNor»r
0 1A(0 ,' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A -
I CERTIFICATION
21 Natharls Way
Property Address: O s t e r v i l l a Address of Owner.
Date of Inspection: If different) /peo 7-5-96 ( ) �Robert Kennedy
Name of Inspector. W.E. Robinson SR ) z
Company Name,Address and Telephone Number. ( 5 0 8 7 7 5-8 7 7 6
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MA
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete.as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sew disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inapbotoes Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A,B;C,or D:
A] SYS PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement repair,passes
on.
Indicate , no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
_ The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street a Boston,Massachusetts 02106 a FAX(617)556-1049 a Telephone(617)262-5500
ice,Printed on Recycled Paper
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 21 . Na th an s Way O s tery i l l e
owner. Robert Kennedy
Date of Inspection: 7—5—9 6
B]SYSTEM CONDITIONALLY PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s).
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of s
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C1 FUR ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
ditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
blic health,safety and the environment.
1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) TBER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 21 Nathans Way Osterville
Owner. Robert Kennedy
Date of Inspection:. 7—5—9 6
DI iTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
a
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
ooliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E1 LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
and safety and the environment because one or more of the following conditions exist:
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 lI of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PropertyA$drOm 21 Nathans Way Osterville
Ow1er Robert Kennedy
Date of Inspection: 7—5—9 6
Check if the fo have been done:
Pump' information was requested of the owner,occupant,
' / m8 �1 pant,and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
1
-As built plans have been obtained and examined. Note if they are not available with N/A.
/The facility or dwelling was inspected for signs of sewage back-up.
Th e m does not receive non-sanitary tary or industrial waste flow
�he site was inspected for signs of breakout.
11 system components, excluding the Soil Absorption System, have been located on the site.
1'he septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees,material of construction,dimensions, depth of liquid,depth of sludge, depth of scum.
he size and location of the'Soil Absorption System on the site has been determined based on existing information or
app ' ted by non-intrusive methods.
The facility owner(and occupants, if different from owner)were provided with information on the proper
P p pe maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 21 Nathans Way Osterville
Owner. Robert Kennedy
Date of Inspection: 7-5-9 6
FLOW CONDITIONS
RESIDENTIAL
Design flow: 3n8
Number of bedrooms: "
Number of current residents:
Garbage grinder(yes or no):_Z—o
Laundry connected to system(yes or no):X—
Seasonal use(yes or
Water meter readings,if available: 19 9 4 86, 000 gals
1995 72 , 000 1s
Last date of occupancy: 7
COMMERCIAL/INDUSTR %.
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-aanitary waste discharged to the Title 6 system: (yes or no)_
Water meter readings,if available:
Last date of occupancy:
OTHER(Describe)
Last date of occupancy: r
GENERAL INFORMATION
PUMPING RECORDS and source of information:
en- /t,'�*n-LrQ4, sVc fi'- i�dS) 6A
System pumped as part of inspection: (yes or no) /1/
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF STEM
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)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information: 12'7 A 574 i
Sewage odors detected when arriving at the site: (yes or no)
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ,
SYSTEM INFORMATION(continued)
PropertyAddrem 21 Nathans Way Osterville
Owner. Robert Kennedy
Date of Inspection: 7-5-9 6
SEPTIC TANK:i/
(locate on site plan)
a '
Depth below grader
Material of construction: 1/concrete_metal_FRP_other(eplain)
L
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 3
Distance from top of scum to top of outlet tee or baffle: "l +
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tges or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.) ell—e a � � O 7-•.�
G
(locate on site fan)
Depth below
Material of co n:_concrete_metal_FRP other(explain)
Dimensions:
Scum thickness:
Distance from to of scum to top of outlet tee or baffle:
Distance from in of scum to bottom of outlet tee or battle:
Comments:
(recommends ' n for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of ,etc.)
(revised 11/03/95) 6
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 21 Nathans Way Osterville
Owner. Robert Kennedy
Date of Inspection: 7—5—9 6
TIGHT HOLDING TANK:_
(locate on plan)
Depth below
Material of n:_concrete—metal_FRP_other(explain)
Dimensions:
Capacity: ono
Design flow: ons/day
Alarm level:
Comments:
(condition o et tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:t./
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUMPjite
l
(locate )
Pumps order:(yes or no)
Comme(note cump chamber,condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 21 Nathans Way Osterville
owner. Robert Kennedy
Date of Inspection: 7-5-9 6
SOIL ABSORPTION SYSTEM(SAS):_✓
(locate on site plan,if possible;excavation not required,but may PP be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits, number:
leaching chambers,number:_
leaching galleries,number•
leeching trenches,number,length:
leaching fields, number, dimensions:
overflow cesspool, number: J
Comment(notepondition of soil,signs off hydraulic)failu�eree, level of ponding,co ti)o of veget/atioa,Jetc.) 6 C� ® C}sl J A A_c
- e C s n k
C LS:_
(locate on ite plan)
Number an configuration:
Depth-top of to inlet invert:
Depth of so' layer.
Depth of layer:
Dimensions o cesspool:
Materials of astr u tion:
Indication of water:
infl (cesspool must be pumped as part of inspection)
Comments: ( condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY:_
(locate on site plan)
Materials of nstruction: Dimensions:
Depth of so
Comments: ( condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
(revised 11/03/95) 8
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Address: 21 Nathans Way oster.ville
Owner. Robert Kennedy
Date of Inspection: 7—5—9 6
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
J
jl✓
' �q 1
L
DEPTH TO GROUNDWATER
Depth to groundwater: l LLfeet ,��
method of determination or approximation: l .' b
(revised 11/03/95) 9
OSTERVILLE, MA
L.-,. N
m
D =
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G R i UTILITY POLE
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DATUM
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ELEVATION
76
_ \�. 6 1.
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oy
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00 ft \�
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Q
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o
LAND COURT PLAN 32225-B
MINIMAL - O/0�,. 'P \ ASSR MAP 122 PCL 66
-GRADING
PROPOSED
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o
o
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f F PROPOSED SOIL
ABSORPTION /
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Q
BACK.
SEE DETAIL
ON BA
V
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59 I 2
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PL AN
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SCALE: 1 in 20 fa ftb
18
PI /
15 in
I O 20 -40. . PINE
PRINT ON 'JI x 17 in THIS IS A ` v
PAPER FOR PROPER SCALE C®L�®Ir� ! 1 vj
PLAN
USE COLOR PLAN ONLY
FOR INSTALLATION
FULL DETAIL IS BEST
VIEWED IN
FULL COLOR {
LEGEND
SEPTIC COMPONENTS
i
1000 EXISTING
E
SEPTIC TANKEXISTING I
OLEACH PIT/ ���H OF 44Ss9r �P��Hk-0F.Mg0A,
DAVID G
CESSPOOL J, p DAVID GJ
D. �, � D. �, �o�T`„ SEWAGE DISPOSAL
DISTRIBUTION BOX 02 COUGHANOWR N COUGHANOWR `f ` v SYSTEM PLAN
® No.1093 No. 461 . -TO SERVE EXISTING DWELLING
TEST PIT 10-
gPPRo��o TIMOTHY AND
SAN � ALA KELSEY BOOTH
OWNER(S) OF RECORD
IF EXISTING LEACH PIT '� ����� 21 NATHANS WAY
TO BE PUMPED AND OSTEAVILLE, MA
FILLED OR REMOVED lbb Ge0 Ryder Rd S PROPERTY ADDRESS
Chatham, MA 02633
i. Dovidcou®HotmaiLcom IDATE: FEBAUARY 11. 2019
' 508 364-0894 Pc.U2 JOBn ETE-4361 �
I
BOLL TEST;. L'Oo � • ' I DEGIO ] CALCULATIONS
NS
:.•
SOIL EVALUATOR: DAVID D. COUGHANOWA. ASE #461 II DESIGN FLOW: 2 BEDROOMS X 110 GPD = 220 GPD
WITNESSED BY: DONALD DESMARAIS. HEALTH DEPT. E SEPTIC TANK: 220 GPD X 2 DAYS = 440 GALLONS
TEST PIT NO GROUNDWATER ENCOUNTERED USE EXISTING 1000 GALLON SEPTIC TANK IF IN
PERC AT 56 in.- 2 MINIINCH IN C SOILS . SOUND STRUCTURAL CONDITION. IF NOT. INSTALL
ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER NEW 1500 .GALLON SEPTIC TANK.
INCHES HORIZON TEXTURE (MUNSELU MOTTLES - -
59.40 0-4 O WOOD LOAM 10 YR 3/2 NONE FRIABLE j DISTRIBUTION BOX: INSTALL UNIT DEPICTED BELOW.
4-7 E LOAMY SAND 10 YR 411 NONE FRIABLE SOIL ABSORBTION SYSTEM:
7-14 A LOAMY SAND 10 YR 4/6 NONE FRIABLE i THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE
56.57 14-34 B LOAMY SAND 10 YR 5/6 NONE LOOSE SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES
48.23 34-134 C MEDIUM SAND 10 YR 6/4 NONE LOOSE PER INCH =_0.74 GALLONS PER DAY PER SQUARE FOOT.
THE 24 ft x 12.5 ft x 2 ft LEACHING GALLERY
TEST PIT 2 NO GROUNDWATER ENCOUNTERED DEPICTED BELOW-CAN LEACH: -
2 MIN/INCH IN C SOILS BOTTOM AREA - (24 x 12.5) - 3C0 sq. ft.
ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER SIDEWALL AREA = (24+24+12.5+12.5)x2 =146 sq. ft.
INCHES HORIZON TEXTURE (MUNSELU MOTTLES I TOTAL AREA = 446 sq. ft.
59.35 0-4 O WOOD LOAM 10 YR 3/2 NONE FRIABLE I FLOW CAPACITY = 0.74 x 446 = 330.04 Sol day
4-7 E LOAMY SAND 10 YR 4/1 NONE FRIABLE
7-14 A LOAMY SAND 10 YR 4/6 NONE FRIABLE INSTALL A 24 ft x 12.5 ft x 2 ft GALLERY AS CONFIGURED
56.52 14-34 B LOAMY SAND 10 YR 5/b NONE LOOSE BELOW. FLOW CAPACITY = 330.04 gal/dog WHICH EXCEEDS
34-134 C MEDIUM SAND 10 YR 6/4 NONE LOOSE THE 220 gal/dog REQUIRED FOR A TWO BEDROOM DESIGN.
48.18 --
I
1
100000 GALLON SEPT§C TANK � �O�L� �,1L� s�0oG�pT00Nl J
EXISTING UNIT — DIMENSIONS & DETAIL M n�
TANK TO BE PUMPED DRY AT TIME OF INSTALLATION 7/ ��u�U CONSTRUCTION DETAIL
AND EXAMINED FOR STRUCTURAL INTEGRITY. INSTALL ( USE SHOREY PRECAST 500 GALLON LEACHING DRYWELL
NEW PVC OUTLET TEE EQUIPPED WITH A GAS BAFFLE. DRYWELL 24.0 ft
REPLACE WITH A NEW I UNIT
1 in 1500 GALLON TANK ' m
TAPER IF CRACKED. ROTTED
OR OTHERWISE
COMPROMISED. 4
c Ln N
° - N
co —
° NOT co"
TO STONE
I� SCALE 3.5 ft 8.5 ft 8.5 ft 3.5 ft
500 GALLON DRYWELL
8 f t_6 in R �� DIMENSIONS & DETAIL INSTALL ONE INSPECTION
RISER TO WITHIN THREE
INLET OUTLET USE INCHES& OF INDICATE FINAL GRADE
COVER COVER H-10
-1TON AS-BUILT
f7mq
33
FROM BUILDI O—BOX48 in
LIQUID GAS
LEVEL, BAFFLE j V2 ;n 5
CROSS SECTION VIEW
FG in STONE BASE IF NEW INSTALL AN APPROVED GEOTEXTILE
SEPARATION BETWEEN INLET & OUTLET
FABRIC OVER STONE
TEES NO LESS THAN LIQUID DEPTH
CROSS SECTION VIEW ~
a a
28 814 in TO - a LEFFE
a 3/4VEa 1-1/2 in GRAVEL
in o a
��� U ������Ouv �OX UDB 3HOREY ; 46 in 58 in 46 in
DIMENSIONS PIPES EXITING D-BOX TO RUN LEVEL 150 in
AND DETAIL FOR 2 FEET BEFORE. PITCHING DOWN
12 in ( -INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE
MIN N STARTING WORK.
FROM -S S I -ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM
n1: TANK TO O REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC
SAS CODE (310 CMR 15).
O o: K T INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND
U UTILITIES BEFORE EXCAVATING FOR SYSTEM.
6 in STONE BASE ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION
��n I OF LOW FLOW FIXTURES & APPLIANCES. AND PERIODIC
21 In 2� CROSS .SECTION VIEW I �' PUMPING OF THE SEPTIC TANK.
i —SYSTEM
DO NOTNOT PPARK ORGNED DR DRIVE TO
VEHICTHSTAND ES OVER SEPTICASYSTEM. G.
(
IF L 0 w P '_jF15) 0 F L E
TOP OF FOUNDATION RAISE COVERS TO WITHIN ALL PIPE �O) B 4 in SCH. 40 PVC
EL = 61.76 +— A 6 in OF FINAL GRADE AND TCH AT 1/8 in/ft MIN
59.5
DD=BO 3'
E��ST0NG 56.5 USE H-20 MAX
EXISTING 1000 Gln1LLO�V °o°voo°0000,°
b
00 °°0000 0000 ogGQO
°O ooO o°°
SEE= TAN 55.83 56.75 �oogop0000 DRYWELL oo°og°o o°�
°o°o °o°o° 0 0
ExISTin
WG REFER TO DETAIL BOX 56.00 ST ONE SOo L ABSORPPTT ON
BASE 55.73
41
EXISTING 6 In STONE BASE IF NEw SYSTEM —REFER TO
74 ft 5-12 ft DETAIL BOX
53.73 NO GROUNDWATER BELOW
MOTTLING OBSERVED - 48.18
SEWAGE DISPOSAL SYSTEM PLAN 121 NATHANS WAY OSTERVILLE, MAJIFEBRUARY 11. 2019 ETE-4361 PG 2/2