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HomeMy WebLinkAbout0120 NORTH BAY ROAD - Health 120 NfOirm BIAy m)p , OS" VHJL a,—� TOWN OF BARNSTABLE LOC 'ION 0 X/O✓ - i SEWAGE # 200U&ll el VILLAGE O 5 /YI/`e ASSESSOR'S MAP& LOT=4��, INSTALLER'S NAME&PHONE NO. 40,yj TO GQ TJ, SEPTIC TANK CAPACITY / 70,0 LEACHING FACILITY: (type) (size) �X3® NO. OF BEDROOMS ' BUILDER OR OWNER D 2 PERMIT DATE: ® '` a` O ) COMPLIANCE DATE: '19/ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet-'of leaching facility) Feet Furnished by 3,io' -� 3 No. THE COMMONWEALTH OF MASSACHUSETTS FEE l�r�Ts—fr�j BOARD OF HEALTH ' OF APPLICATION FOR DISPOSAL SYS FM CONSTRUCTION PERMIT Application for a Permit to Construct ()C) Repair ( ) Upgrade ( ) Abandon ( ) - ❑+Complete System ❑Individual Components mtvc Location wner's Name 7 y 2�—� �D �d► � .,� N dJ Map/Parcel# Lot# ! C ✓Teleph ne# 0 4� ntaller's Designer's a e Telephone It Telephone# Type of Building: Lot Size Sq.feet Dwelling—No.of Bedrooms ez— Garbage Grinder ( ) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures 2 � Design Flow(mi r qui ed) ZIP gpd Calculated design flow Z 2S gpd Design ro ided 2 f gpd Plan: Date Number of sheet Revision Date �� Title < Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to pla the system in operation until a Certificate of Compliance has been issued y the Board of Health. Signed Date JZ © IS - Z 10 FORM t - APPLICATION FOR DSCP DEP A14PROVED FORM 5/96 .. c sa THE COMMONWEALTH OF MASSACHUSETTS FEE2�, BOARD OF HEALTH OF ..r- APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT r.9 Application for a Permit to Construct (K) Repair ( ) Upgrade ( ) Abandon ( ) - ❑Complete System ❑Individual Components.;r Location wner's Name Map/Parcel# T d7 Lot# ✓� Telek/# �r 0 Dfi� n �Gtaller'spla / Designer'sN` e i t y dress ! Addr s -Telephone# Telephone# • Type of Building: 91 Lot Size Sq.feet Dwelling—No.of Bedrooms Garbage Grinder Other—Type of Building s No.of persons Showers ( ), Cafeteria ( ) vi Other,fixtures Design Flow(mig.r quired) gpd Calculated desiy flow ?2 S gpd Design 0 to ided ?�.S gpd Plan: Date CGS 'Ls'7r-1- Number of sheets Revision Date j J , , Title:. Description of Soil(s),F i Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation.. DESCRIPTION OF REPAIRS OR ALTERATIONS l The undersigned agrees to install the above described Individual Sewage Disposal System in accordance'with the provisions of w TITLES and further agrees not to place the system in operation until a Certificate of Compliance has been issued py the Board of Health. t Signe d, Date IZ �� kr� Inspectio`Ft's e -.0 FORM I - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. Af L- I ;P, THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( ) by: o1r�� f C��� '✓ r at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application N ated /!r 6. flApproved Design Flow (gpd) Installer � Designer: Inspector Da"te 1 � O The issuance of this certificate shall not be construed as a guarantee that a system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROV D FORM 5/96 No.IG�Aol, d/& THE COMMONWEALTH OF MASSACHUSETTS FEE lwd BOARD OF H EALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct ( Repair ( U grade ( bandon ) an individual sewage disposal system at as described j in the application for Disposal System Construction Permit No. .�9000 dated /d 4 90co. Provided: Construction shall be completed within three years of the date of this permit.All local conditions must be met. Date �1 J a D I Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96, r t FORM 1255 (REV 5/96) H&W HOBBS&WARRENrM PUBLISHERS- BOSTON TOWN OF BARNSTABLE LOCATION l Z /l/0 o-� g d V �p� SEWAGE # 200a yll q VILLAGE 1,7 Ile ASSESSOR'S MAP & LOT r INSTALLER'S NAME&PHONE NO. G�dyst,T�Gp 77 I SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) 1VV.OF BEU1KUVMS BUILDER OR OWNER D 'j PERMITDATE: ® / a` DQ COMPLIANCE DATE: /,2"V/ . Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private VV,aEerSupply Well and Leaching Facility. (If any wells exist i on sitebr within 200 feet of leaching facility) Feet- Edge-of Wetland and Leaching Facility(If any wetlands exist within 309 feet:of leaching faciliay Feet Furnished by j } .. - >m _ z6 0'.. .. V 1'0'� .,}i `J...S'.................... Z ..... ........ ......... LLJ V I A 0 o iii 7 1 .._I..... ........__ ...... ........ _ _ - --� _-_._................. 'm r : P Y III�� I Oi � E � W•I �� ' I {..... �. 029T RIDGE j{ 1tl�, I , �..........5LOPED O I Q CEILING IN5ULATE ALL inl 5 6 IIhr', I BATH AND -- — - I TUB/5HR. I WALL5 W/P-19 I - I 'q . F.G.BATT5.--- - I I PH.: I F ., BEDROOM #2 i , E _ I .._.4'-3".-..-X - 3'-6" ., ..._ -6" X1'-6"� . 3'-t0"--._ o� C BATHROOM I pl I AIR I1ANDLEk I ! I a All IC I 204 -7 t I 203 ' �uL gut ......� I Q PULL DOWN /20711 I IZ LADDEP _ , j 06 l- \'..._1 a! of i C _... f. CLO L..CLO HALL i 1Di o O i; o �\ N V) /O'Ln � 04 BEDROOM#1 ! Q i, M , L1J i I Lu -- ._ LANDING i n SLOPED LLJ •- �' CEILING (L RIDGE CL co 1 ' ..... ..... ................... # �....... _WAL BELOW O N tl ' �I. ' T 0 j.. .. 5:1:: * L U O $ rn f# X.................... . -XI +�! SECOND FLOOR PLAN 1.... _ t ...... 26'.-0......... .... �i . a yF , v Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;M 120 North Bay Rd. (main House) Property Address Michael Champa Owner Owner's Name information is Osterville Ma. 02655 6/3/2011 required for , every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information forms on the I _ computer,use 1. Inspector: only the tab key p� to move your Robert Paolini cursor-do not a "' use the return Name of Inspector O key. Capewide Enterprises,LLC. C73- Company Name sCD f� P.O.Box 763 Company Address Centerville Ma. 02632 c City/Town State dip Code 1—n r�tt (508)477-8877 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority e�zldlr?J4— 6/3/2011 Insp cr's Sin re 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. { � t5ins•11/10 Title 5 Official Inspection Form:Subsurface Se ag Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °,M •'°� 120 North Bay Rd. (main House) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 ' every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M 120 North Bay Rd. (main House) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M 120 North Bay Rd. (main House) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. CityTrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to AII.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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 120 North Bay Rd. (main House) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This F system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ ® 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be f necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No X ❑ ❑ 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 a ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IW PA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 120 North Bay Rd. (main House) Property Address Michael Champa Owner Owner's Name information is Osterville Ma. 02655 6/3/2011 required for every page. City[rown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? 0 ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable).[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•11/10 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 6 of 17 I , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M .' 120 North Bay Rd. (main House) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: y Number of current residents: NA ' Does residence have a garbage grinder? ❑ Yes ® No 8 Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No q Seasonal use? ❑ Yes ® No 2009:452,000 Water meter readings, if available (last 2 years usage (gpd)): 2010:238,000 Detail: Sump pump? ❑ Yes,® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 120 North Bay Rd. (main House) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspectibn Form:Subsurface Sewage Disposal System•Page 8 of 17 F. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 North Bay Rd. (main House) Property Address Michael Champa Owner Owner's Name information is Osteryllle Ma. 02655 6/3/2011 required for every page. Cityrrown State Zip Code Date of Inspection Z D. System Information (cont.) 9 Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 2'5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon 6" Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 120 North Bay Rd. (main House) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2611 Scum thickness 1" I 5" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 A� f , . , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 120 North Bay Rd. (main House) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight 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 Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;M 120 North Bay Rd. (main House) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage. 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.): ;f ,� II r 3 Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 North Bay Rd. (main House) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 4'x35'x2' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Leaching trench was dry at time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �^M 120 North Bay Rd. (main House) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): : r Privy(locate on site plan): Materials of construction: Dimensions ,e Depth of solids Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): a t z* t � I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r x r1 !1Je K ��� rE�,E.`. /�"�`s`v}1Ir����� ���'=€-"yP� tt�r.� *�k a�„�� 7•'�T�,'�t�'1'�`';''�A�'� -°ty.� Y.It 'L r.•-,.4r v ��''i er'� v .CF �s t, N d �'Y>k' �: I .� _a .: +.r t F$§g ��,� c,�N, i� ,� 2 �d�c �� 'a,3ezL✓ ' ®� ��• "-t-e `{"k `s.n'o,,+`'ry,�xt L, ,x. x,,"Ar's,�✓. i7 'Y-wrs..�aCy:sS'� z by. "'WnL r cry rn fa .k. ✓4 M Mr c.YtrXw +..�a..`� $terT y,7�3.x. tM �c..e aiw3lr-��;•" �� �' +i'��t^�t�F�`r,��n�. -�-�'^r v "ea'�„r�. ��,. a s} x j � }sty P tiffs & h'�` ,q5, 1• .: ✓"�§, rah s 3 $ a c ssrs �ifs � ,I�✓is,sA"���,,��,.,�� �vl'���r��`e q��'t'���"nw �"�'°i,-'��`�+�y`'�"�",�'4 Y x' , b EF ,�� �� {,,� � rr`tra+t• �Rk Ie Y'� ,�f,���?�,��.Q��"�`•'s� rc+�'a�"� k e a b r r ra rA N - '•� "+010`�u" F, '� F,� y"Ytq._ vf• d' ,113 kF�Y. lS r �j ��� fi� ,,yy�[,' �'� Y Y$ .�". < ,:r•F.y .f"t.""^'9s q 3 ao-r"` ZVOWRiN, 5.ml R1:; �. � A w# S B h 'ri5fla.- W ✓, INTO" •Y j" �5 cT. . .I r -•� �''3 �:�s.� �.Y�e -3'�'�' d t �"�wt y�""� J£:�.i`;"> t�,a5� #t y`'�' l-r,�•. N mgup g M�h�a`e'ufc�``s4•�z�,�����ilo-3'` rt� �" '�rs7��'��rc'w°t'�'•� A3 w ki y 4 6� wt '�':..'`.i��Y S ✓"�;a'�'^M'3+;�n'�v:b' �r��tl rtt�`r�x',�F� "4`'' a ."vpvF �` '- ,� yt. y •r -��'� Ste''""�� ��'9 "�"r, � 4'`� �k 5 P' ,P�• N�7, f "`' i, Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 120 North Bay Rd. (main House) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection ` D. System Information (cont.) Site Exam: ` ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells f Estimated depth to high ground water: Bottom of Leaching 8' . 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: As-Built ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;M 120 North Bay Rd. (main House) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t p e Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ` 120 North Bay Rd. (Cottage) 1y Property Address ' Michael Champa Owner Owner's Name information is required for Osteryille Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection ih Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1 onlythe tab key1• Inspector: I M Q � t(:move your cursor-do not Robert Paolini , _ Name of Inspector 1 use the return a. 1 . key. Capewide Enterprises,LLC. w , Company Name t t� P.O.Box 763 ( `.•.� e.e� Company Address Centerville Ma. 02632 City/Town State Zip Code- ° (508)477-8877 S 14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority e114 ex, 6/3/2011 Inspector's Ignature 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. I4 t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewa a is osal S ste •Pa I 1 of 17 P 9 P Y 9 t , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments 120 North Bay Rd. (Cottage) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection t 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 E in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: i �v The septic system is in proper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 120 North Bay Rd. (Cottage) Property Address Michael Champa Owner Owner's Name information is required for Osteryllle Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board.of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 120 North Bay Rd. (Cottage) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. 1t_ Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 120 North Bay Rd. (Cottage) Property Address Michael Champa Owner Owner's Name information is required for Osteryille Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 120 North Bay Rd. (Cottage) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection C. Checklist y t 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 i ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? Were as built plans of the system obtained and examined? (If they were not { ® ❑ available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 120 North Bay Rd. (Cottage) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 ears usage d 2009:452,000 g ( y g (gp ))' 2010:238,000 Detail:- Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 3 '°M 120 North Bay Rd. (Cottage) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date x Other(describe below): t F General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments wM 120 North Bay Rd. (Cottage) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page.. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: e61 et Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints appear tight.no evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 2" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments -^M 120 North Bay Rd. (Cottage) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" ' - Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ;M 120 North Bay Rd. (Cottage) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 City/Town/Town State Zip Code Date of Inspection every page. Y P P D. System Information (cont.) Comments (on' pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date•of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 North Bay Rd. (Cottage) Property Address f Michael Champa Owner Owner's Name information is Osterville Ma. 02655 6/3/2011 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): ( Depth of liquid level above outlet invert No x 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.): Box is Ievel.Box has three outlet Iaterals.No evidence of solids carryover.No evidence of leakage. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 120 North Bay Rd. (Cottage) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-Flowdiffusors ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs of hydraulic failure.Leaching was dry at time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form. Not for Voluntary Assessments ^M 120 North Bay Rd. (Cottage) ` Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth.of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page 1 of 2 4 Town of Barnstable Geographic Information System Parcel Viewer I Custom Map Abutters. Map Size zoom out �In a $�� zr�j� 3 � J i i' rF +,1 a° ';,CF 14 - r �1r't�t!Sr�' �' "at Gi��riW�l�' 4 wiz w7 `� � m•. a f} 'c'w �� :�. �. "4n'S '� � �%�, ;{��aN'�'I • ,' II��'�k :I t t ,��,!t���r ��.pRt u ;;4 I OFF I, h ex�of ;��+' ; {,++�+ �wiFii�„�k'tf.' 6 � � ..d�f�£9KKhhc�'i� ��F4 ��,���� ��.�, ���''���' '� +�• .,�� !M"', 5;�,�P�� .�7 y, � e '• S�t�.r7. jrtV� ll� i.�t:t��4�.r� -�._yr v Y r,��,y�',,�i �-�+4Y^r� iud �' ':1 yy" ' c i i Ne $ +'3 01 VIA # .. Feet Set Scale 1" = 20 p I Aerial Photos ' I MAP DISCLAIMER (:nn..rinhf Jn 0r-9 10 Tn...n of P-faKln NAA All rinKfe rc-- http://66.203.95.236/arcims/appge.oapp/map.aspx?propertyID=072028001&mapparback=0... 9/21/2003 • 4 L w Commonwealth of Massachusetts L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 120 North Bay Rd. (Cottage) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of Iraching 6' 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: As-Built ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: USED:USHS Observation Well Data.USED:Technical Bulletin 92-0001 plate #2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 120 North Bay Rd. (Cottage) Property Address Michael Champa Owner Owner's Name information is required for Osterville Ma. 02655 6/3/2011 every page. City[Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 s 1 DATE. . 2/26/QQ PROPERTY ADDRESS 120_North _Bay _Road_____ OstervilleL Mass ` _ ---- 0 26 5 5 _ _ ---- ---- on the above date, I. Inspected the septic ,system at the above address. This system consists of the following; 1 . 1-1500 gallon septic tank. 2 . 1- Distribution box . 3 . 1-35 ' x4 ' x2 ' leaching trench Based on my Inspection, I certify the following conditions: 4 . This is a . title five septic system. ( 78 Code ) 5 . The septic system is An e,propr . working order at the present time . } 6. Sewage pump in the 1-ower level . 7 . Old cesspool was omitted . - ` m ' SIGNATURE: Company: Jose.Rh_P__Macomber_& Son , Inc. - _ Address:--Bo— x_-66 6 ------------ CentervilleL Ma _02632-0066 Phone:___508 775_3338___—___ THIS. CERTIFICATION DOES NOT-CONSTITUTE A 'GUARANTY OR. WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks•Cesspools•Leachf lelds eMc Pumped & Installed Town sewer ConnA102632-0066 P.O. sox 66 Centervills. 775.3338 775.6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292.6500 TRUDY CC Secret ARGEO PAUL CELLUCCI DAVM B. Sq RU mm;.. Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM � � PART A CERTIFICATION Property Address: 120 North Bay Road Name of owner T e r e n,c e M c C l i dc h Osterville ,Mass . AddrassofOwn ; 9r)AI ( r)nnress Street Data of lrupectton: 2/16/0 0 Fairfield Conn . 06430 Name of lrupector:(Ptaase Print) Joseph P.Mac o m b e r Jr . 1 aim a DEP Wp�oved system Inspect"pursuam to Section 16.340 of Thie 6(310 CUR 16.000) m copanyn Naw: J. Y .Macomber & Son Inc . MmTaVAddress: Box 66 Centprvi 11 p rMaSc 02632 Telephone Number: 598 CERTIFICATION STATEMENT " I certify that i have personally inspected the sewage disposal system at this address and that the Information reported blow Is true. accurst* 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•slte sewage disposal systems:. The system: Passes Conditlonally Passes " Needs Further Evaluation By the Local Approving Authority _ Fails. Inspectors Signature. Data: The System Inspecto all a brrJ a copy of this insp Lion report to the Approving Authority(Board of Health or DEP)w)thin thirty (30) days of completing this Inspection. If the system Is a shared system or has a design flow of 10,006 gpd or greater,the Inspettor and the system owne shall submit the report to the appropriate regional office of the DapartmenT cKmvironmenttd Protectlon. The original should t»sent toVw system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS Pla yV. - MAR t �.� 10WF10FBPNNSTABt£ R� ;y�•?I{DEPS• a revised 9/2/98 Paeelofll r '. tv,Prinld on Racycld Prpu I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A k i CERTIRCATION(con*wed) NoWtyAddress: 120 North Bay Road Ostervilie ,Mass . - Owner Terence McClinch , Data of Inspection:2/16/0 0 YlSPECTION SUMMARY: Check A, A C, or D. A. SYSTEM PASSES: I have not found any Information which Indicates that any of the failure conditions described in 310 CMR 1S.303 exist. Any failure criteria not evaluated are indicated below. COM1 E?M: k B. SYSTEM CONDITIONALLY PASSES: One or more system components as described In the 'Conditional Pass' section need to be replaced or repaired.-The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes,no,or not determined(Y. N, or ND). Describe basis of determination in ate Instances. If 'not determined', explain why not. The septic tank is metal,unless the owner or operator has provided.the system Inspector with a copy of a Certificate of Compliance(attached)Indicating that the tank was Installed within twenty(20)years prior to the date of the Inspection; or the septic tank, whether or not metal,Is cracked,structurally unsound,shows substantial Infiltration or exfiltration, or tank failure Is Imminent. The system will pass Inspection If the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. i( Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pips(s)are replaced obstruction is removed distribution box Is levelled or replaced The system faquired pumpMg-more than•fourZfines s-yeardus to broken or of ftcted pipets). The system w*Tc s-- Inspection If(with approval of the Board of H"th): broken pipe(s)are replaced obstruction Is removed - _revised 9/2/98f Page 2oru SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Prop"Address: 120 North Bay Road Osterville ,Mass . Owner: Terence McClinch Date of Inspection: 2/16/0 0 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: VA Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.YALL.PRQTECT THE PUBLIC HEALTRAND SAFETY AND THE ENWBONMENT. Cesspool or privy is within 50 feet-of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 41/ 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. 10 The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the prey nce of ammonla nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance _(approximation not valid).- 3) ,OTHER /vlL N� revised .9/2/98 Page 3orll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1 CERTIFICATION(continued) Property Address: 120 North Bay Road Osterville ,Mass . Owner: Terence McClinch Date of Inspection:2/16/0 0 D. SYSTEM FAILS: Youmust indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this determination Is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No / Backup of-sewage irrlofaciRty-er-eystdm component due%to an overloaded ormleg god-S,AS-or-cesspod. y---- - ' Discharge or ponding of.effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static-liqui level in the distribution box above gutlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth incessslroel-is less than 6" below invert or available volume is less than 1l2 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 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 -coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. - E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes N the system is within 400 feet of a surface drinking water supply the system-is-within 200 feet AsuFfaoe•dAnl&i49.4*ater-#UP0y 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further infor,(nation. revised 9/2/98 Page 4orit SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA c PART C , SYSTEM INFORMATION Pr*p Addres:: 120 North Ba'y Road .0stervi11e ,MasSL. Owner. Terence McClinch Dou of kupec*m: 2/16/0 0 FLOW CONDITIONS' RESIDENTIAL Design flow: i1b g.p.d./bodrogp. , Number of bedrooms js�ig Number of bedrooms(actual): Total DESIGN flow_ "V b Number of cuff ant residents Garbage grinder(yes-or no): + Laundry(separate system) ea Oro ;,.If yes,sepacau.1aspaction•retiulmd -- Laundry system Inspected yes r no) Seasonal use(yes or no): AU Water meter readings,if evall ble(last two year's usage(gpd): Sump Pump(yes or no): j 7074 G. Last date of occupancy:, COMMERCIALANDUSTRIAL: Type of establishment: Design flow: d ('Based on 16.203) Basis of design flow Grease trap present: (yes or no).Abf A industrial Waste Holding Tank present:(yes or no)/� Non-sanitary waste discharged to the Title 6 system:(yes or no)" Water meter readings,If available: AW Last date of occupancy:_ OTHER:(Describe) Last date of occupancy: -. GENERAL INFORMATION. PUMPING REFORDS d sourc o information: U ; � IN System pumped as part of Inspection:(yes or no),L If yes,volume pumped: gallons Reason for pumping: TYPE OjrSYST _ )/ EMASeptic tank/distribution box/soil absorption System Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous Inspection records,if any) l/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other TE AGE of all compopprits, date insta a {if know and a tion:— I4-r .,, 0 r , - Sewage odors detected when arriving at the site:(yes or no) revised 9/2/98 PQes6ofI' ' , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ± ProwtyAddress: 120 North Bay Road .0sterville ,Mass . Owrw: Terence McClinch Date of Inspection:2/16/0 0 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes N Pumping information was provided by the owner, occupant, or Board of Health. None of the system compownts kam&A~puaNwdjAos<atJaasttwoweakaaaddw*rystem hasbaeoascaiwagweasai flow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this inspection. _ 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. The system does not receive non-sanitary or Industrial waste flow. _ The site was inspected for signs of breakout. _ All system components,/�e+�ecluding the Soil Absorption Systemave been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: _ Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at Issue,approximation of distance is unacceptable) 115.302(3)(b)) The facility owner(and.occ,,paats,if diffaraW from..ownef).iweraprauidadawith int—matiomA)n.tb 4uTQr nsntaasM&of SubSurface Disposal Systems. revised 9 2 98 Page 5 of I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMA PART C SYSTEM INFORMATION(continued) P►opertyAddress: 120 North Bay Road Osterville ,Mass . Owner: Terence McClinch Deta of 4upecti°'r 2/16/0 0 BUILDING SEWER: (Locate on site plan) / Depth below grader Material of construction: • cast iron�40 PVC other(explain) Distance fTomAdvate water supply well or suction line Diameter 311, Comments: (condition of Joints, venting,evidence of leakage,-etc.)Joints appear ti hi- Mn gyi aonro ref leakaSe . S �vs (locate on site plan) Depth below grader Material of construction: concretemetaL(j�Flberglass��Polyothylons tl�other(explain) If tank is Enetal,list age d 1s.age.confirmed by Certificate of Compliance (Yes/No) Dimensions: '/rr Sludge depth: AIF G(/ V �i! Distance from top o udge to bottom of outlet tee orbaffls. - Scum thickness: Distance from top of scum to top of outlet tee or baffle:2y4ft4- Distance from bottom of scum to botto of outlet tee r baffle:_2deoy`s How dimensions were determined: Comments: (recommendation for pumping, condition of Inlet and outlet tees or-baffles,depth of liquid level in relation to outlet Invert, structural-integrity, evidence of leakage,etc.) Pump septic tank annual GFirhagP t►i s=nGal 4 is present1. TnlPt k n„flPt tcnac nre�reeelit . bigu}d JeveI al; 1e soun n GREASE TRAP: (locate on site plan) Depth below grade:-d)-14 Material of construction A4*concrete4/Ametal4A/ Fiberglass��PolyethyleneA#other(explsin) A/!4 Dimensions: JJV Scum thickness:—A!d Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle:�f1� Date of last pumping: A/9 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet Invert, structural Integrity, evidence of leakage,etc.) Grease trap is not Ares nt revised 9/2/98 Page 7of11 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART C SYSTEM INFORMATION(continued) PropertyAddress:120 North Bay Road Osterville ,Mass . Owner: Terence McClinch Date of Inspection: 2/16/0 0 TIGHT OR HOLDING TANK• .UX(Tank must be pumped prior to, or at time of, inspection)' (locate on site plan) Depth below grader Material of construction:44 concrete{metal,VgFiberglass,12Polyethylene V other(explain) AA Dimensions: AA Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:YesAA NoIN Date of previous pumping: AM _ Comments: (condition of inlet tee, condition of alarm and float switches, etc.) 'light or holding tanks are not present DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: tit) .. Comments: (note if level and distribution is equal, evidenoe of solids carryover, evidence of leakage into or out of box, etc.) — - — Distribution box has one lateral - Nn Fvi dpnre of and i d- r-ggy njror PUMP CHAMBER:-415- (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Pump chamber is in goon rnnrli ti nn Piimp i c in onnrl rnndi ti nr, and nparnting properly . Mandl.ea lower level bath and laundiry and revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ;. SYSTEM INFORMATiON(condnued) PropertyAddresa: 120 North Bay Road Osterville ,Mass . own«: Terence McClinch Darla of Inspection: 2/1 6/0 0 SOIL ABSORPTION SYSTEM(SAS):_ (locate on sit@ plan,If possible:excavation not required,location may be approximated by non4ntruslve methods) If not located, explain: Type: • leaching pits, number:, leaching chambers,number: leaching galleries,number. leaching trenches,number, length: leaching fields,number,dime &Ions: overflow cesspool,numb* : Alternative system: Name of Technology: I r 1 P F i v e ]8. Code . Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) oamy sand to medium fi nP ,;and - No ci gnc� nf hjrrIra>>1 i CESSPOOLS: (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(cesspool must be pumped as part of Inspection) Lps,snnn) s era not i roonji-i- - Comments: (note condition of soil, signs of hydraulic failura,.level of ponding,condition of,vegetat(on, etc.) --Cesspools are not present PRIVY: ' (locate on site plan) ff Materjals of conatru�, on: i[/l Dimensions: /L Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 120 North Bay Road . Osterville , Mass . Ownw: Terence Mc Clinch Date of Inspectfon:2/16/0 0 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes Into house) '-ter F It 0A/r revise 98 �) 20 O•NEIL AGENCY 5087782314 C, TOWN OF BARNSTABLE -LOCATION .120 .:NORTH BAY ROAD SBWAGB # �VILLAGS ntTFAviiI F ASSESSOR'S MAP & LOT INSTALLER'S NAMB 6 PHONE NO, ELLIS BROTHERS CONST 362-6237 SEPTIC TANK CAPACITY ZS TO U LEACHING FACILITY.(typc) l�� , z (size)_3r��/�,J NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATERAle/G BUILDER OR OWNER �-u � •.: DATE PERMIT ISSUED:_ DATE COMPLIANCE ISSUED_ VARIANCE GRANTED: Yea No 02 7 F� --yYO�' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C v SYSTEM INFORMATION(continued) Property Address: '120 North Bay Road Osterville ,Mass . Owner: Terence McClinch Date of kupection:2/16/0 0 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked r Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells r Estimated Depth to Groundwater Feet' Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record bserved.Site(Abutting property observation hole, basement sump etc.) Determined from local conditions J//Checked with local Board of health Checked FEMA Maps ,e Checked pumping records Z' Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours map . Gahrety & Miller Model 12/16/94 revised 9/2/98 Page II or II t• rn*5T n:•rs*^•rrrn. mr•nsetls-+rrt ren.rrlr:•.•R+:T�n+sr*s*+rrn tr�r+ty Tss7nir.nr�+ .T1.'lrrlr�r�:..--.r-.. TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAOF DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION •••T"t^T••.••.•f-�,t l►^.�TTt 1S T.'In•1f.'f1H T.1►.R{'.f 7RTT1:�'^'f-lV1'R'�7.RRA►^TTIT�'f tT�A.11tnR7 tRn 11 ..�I•T'T.•1.-.. -TYPL OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 120 North Bay Road Osterville ,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # 72-28. 001 OWNER' s NAME Terence McLinch PART D - CERTIFICATION r NAME OF INSPECTOR Joseph .P.Macomber Jr . COMPANY NAME J . P.Macomber & Saif 'Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02532 Street Town or City State LIP COMPANY TELEPHONE ( 508 I 775 - 3338 FAX (790 1 1578 - !.t At CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in ,the proper function and maintenance of on- site sewage disposal systems . ' Ch.ec�k one : v System PASSED , The inspection which , I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* \ The inspection which I have con acted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . - ( 1 Inspector Signature �dwDate �l ne copy of this certification must be provided to D . the OWNER, the BUYER . ( where applicable ) and the OARD OF HEAL1`ll. If the inspection FAILED, the owner or"" erator shall up grade pgrade ' the system' within one year of the date of the inspection , unless allowed -or required otherwise as provided in 3.10 CFIR 15 . 305 , partd .doc., 9-29-1998 7:45AM FROM JOHN CONATHAN II 5084283S26 P. 1 .01/09/1994 02:14 508-790-1578 J.P.MACMiEER & SON PAGE 02 r �, 'To U of arnstable $ Department of Yjealth ,Safety,and Ettvironmeathl Services K Public Health Division 367 Main Stree% s MA 02601 Office: M-79"265 FAX: SM7904304 'lhammmm A.McKewr 2s,CHO Duador of Public fTaa6b January 2, 1999 J.P.Macomber dt Sons,Im. J-P.Macgwber,If. Box 66 Cemtt tville,MA 02632-OOM RE: 120 North Bay Rd.,Oyster Harbors,osterrille,MA Dear Mr.Macomber, After Au'ther review of your December 9, 1997 septic impaction report for the above referenced property, the septic system was determined trot to meet failo re criteria pertaining to tlae estimated h elevation hi$ groundwater Yaar inspection report indicated that an adjustment to the observed grvaadwater determlaed in test hole performed on 9/14/95 would cause the cesspool,located 64 feet f m tidal to fail by the groundwater criteria. A field survey performed by the Bantstable public Health Division measured the average tidal variation (wrack liac)to be lower than the bottom of the mil. Therefore,the cesspool is not below the seasonal high groundwater table. Ityou should bove telhave any questions or Comments,please do not heesitate to call me or Glen Harrington,R.S., at the aephone number. Thomas McKean,&S.,CHO Director of Public Uvalth. Dear Sir: The sewage system and septic system at f20 North BAY Road t?stervi,lle,Mass has been approved by the Barnstable Board Of Health. The Conditionally Passed report now becomes a past report. Review was requested by Joseph P.Macomber Jr. , I DATE : 12/9/A97 DEC 11 1997 PROPERTY ADDRESS: Robert -DePasqua .F J TOWN OF BARNSTABLE 120 North Bay Road p� HEALTH DEPT \4 p, �� Osterville,Mass . ( Oyster Harbors )��' �' �. _. On the above date, I Inspected the septic system at the •above address. This system consists of the following: 1 . 1 -1500 gallon septic tank. 4 . The cesspool is on the 2 . 1 -Distribution box. Oceanside. 5 ' x5 ' 35 ' x4 ' x2 ' leaching trench. 3 . The system is on the street side. Based on my InPo�ectlon, I certify the following conditions: 5 . The—Street system is a title five"septic system. ( 78 ) 6 . This system is inproper working order. 7 . The cesspool on the oceanside is 1 ' off the water table. 8 . Make the adjustment and the cesspool is- in the water table. , This cesspool must be omitted. All wastes discharge( the cesspool must pumped to the title five septic system on the streetside of the house. - SIGNATURE Name : J . P , Macomber Jr... i Company:_J . P'Macogber &_ Son- ,Inc , rddress :_-566------A------ CentervilLe `Mass__02632 Ph one : 5aa-27_ —______ I THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY }OSERH P, MACOMBER & SON, INC. TankrCt"PoolrLaschlleld; . Pumprd 4. In;tillyd Town Sewer Connection; P.O. Box 66 ' Centerville, MA 02632.0066 775-333 775-6412 -\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS _ DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. MA 02108 617.292.5500 u ILLIANI F WELD TRl DY COXE Go.cmor Secrewy ARGEO PAUL CELLUCCI DAVID B STRURS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION Property Address: 120 North Bay Road Osterville Address of Owner: 83 Arnold Road Date of Inspection:12/9/97 (If different) Newton,Mass.021 59 Name of Inspector:Joseph P.Macomber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son Inc. Mailing Address: BOX 66 Centerville,Mass _ 02632 Telephone Number: 508-77ci--4338 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 sesva a dis osal systte'ms. Th system: Passes C' VC ,QA n? P Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: / 1 �� Date: The System Inspect all Lsubmit 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) SYSTEM PASSES: A,-)O 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. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: -zXei;- One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. A0 The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:l/www.magnet.state,ma.us/dep Printed on Recycled Paper I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 120 North Bay Road Osterville,Mass . ( Oyster Harbors ) Owner: Robert DePasqua Date of Inspection: 1 2/9/97 131 SYSTEM CONDITIONALLY PASSES (continued) 4/0 Sewage backup or breakout or high static water level observed in the distribution box is due to oroken or oos:!,...-c pipe(sl or due to a broken, senled or uneven distribution box. The system will pass inspect,on if twin aporo�a, o: :— Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced J( 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 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 ;o arotec the puohc health, safety and the environment n SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT•FUNCTIONING IN A .ti1,avNER 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 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETER.tiiINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface waters pp:: o tributary to a surface water supply. A!Q The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supp:, tee!• The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more iro•rn a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds nccates tna: the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is ec..ai to o! less than 5 ppm. Method used to determine distance RrfZt (approximation not valid) 3) OTHER eS}�r3'd s'✓lG�S7" Jss�JT—' � `/L�T� �•� d�.�!" .� %� ' s 5. od� (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ± Property Address: 120 North Bay Road Osterville,Mass. ( Oyster Harbors ) Owner: Robert DePasqua Date of Inspeclionl 2/g/g 7 f) ( D) SYSTEM FAILS: .?O You must indicate el.- et "Yes" or -No*' as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 Cnt,R 15 303 for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to coRE the failure. Yes No i Backup of sewage into facility or system component due to an overloaded or clogged SAS or cessDoo! Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or cloggee o, cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspoo' Liquid depth in cesspool is less than 6" below inven or available volume is less than 112 day f!o,, Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipes) 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 tnbutan, to a surface paler supp Any ponion of a cesspool or privy is within a Zone I of a public well. Any ponion of a cesspool or privy is within 50 feet of a private water supply well. Any ponion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water suppiv weir wit,n acceptable water quality analysis. If the well has been analyzed to be acceptable, anach copy of well -ales anaivs,s c colrform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen El LARGE SYSTEM FAILS: you must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above. The system serves a facility with a design flow of 10,000 gpd or greater (large System) and the system is a s,grwican: ;area; tc public health and safety and the environment because one or more of the following conditions exist. 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 mappec Zone 1: o: 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 treat,,yen! Droz�a- requirements of 314 CmR 5.00 and 6.00. Please consult the local regional office of the Depanment for further informat,o Ir.v I..d 01/75/97) ➢&9e 3 of 10 A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Robert DePasqua Owner: 120 North Bay Road Osterville,Mass. ( Oyster Harbors ) Date of Inspectional 2/9/9 7 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes N / Pumping information was provided by the owner, occupant, or 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 recentkv or as part of this inspection. _ 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. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, All ding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) 1 . The cesspool on-'the Oceanside of the house is 12" off the water table. The cesspool is also within 64 ' of the marsh grasses and the oceans edge. 2 . Make_the water table adjustment., the_ c.e.sspool -is in the water table. 3 . Cesspool mu�X omitted.All laundry water sink water and any other discharge to the cesspool must be omitted. This can all be put into the sewage ejection system that is already in the lower level . (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 120 North Bay Road Osterville,Mass . ( Oyster Harbors ) Owner: Robert DePasqua Date of Inspection: 1 2/9/97 FLOW CONDITIONS RESIDENTIAL: Design flow._ .P.d./bedroom for S.A.S. Number of bedrooms: Number of current residents:'t '' Garbage grinder (yes or no). ` Laundry connected to system (yes or no): i�' k• 'f%u !h�nn��`!` ,,�, �I 777 Seasonal use (yes or no):_ 7'/ & Cam: lj `U�r'� Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (yes or no):—All0— Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establ'shm nt:_ Design flow: - ';�gallons/day Grease trap present: (yes or no)A�/� industrial Waste Holding Tank present: (yes or no)A? Non-sanitary waste discharged to the Title 5 system: (yes or no)40 V,'arer meter readings, if available. ,1 fit Last date of occupancy. /U/f OTHER: (Describe) Last date of occupancy. Allyf GENERAL INFORMATION PUMPING RECORDS a d source of information: ��s1AA, System pumped as pan of inspection: (yes or no)� If yes, volume pumped: gallons Reason for pumping TYPYSTEM Septic tank/distribution box/soil absorption system -1 Single cesspool Overflow cesspool ,yin Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) e�J I/A Technology etc. Copy of up to date contract? Other X-11t APPROXI TE AGE of all co m on s, date instilled (if known) and sourcq of information: ��l,C:. ♦y jk fy�� ; /, —, Sewage odors detected when arriving at the site: (yes or no) (revised 04/25/)7) Daq• 5 of 10 SUBSURFACE SEwACE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 120 North Bay Road Osterville,Mass . ( Oyster Harbors 0"ner: Robert Depasqua Date of Inspection:) 2/9/97 BUILDINC SEWER: ;Locate on site plan) rr; Depth beloN grade. Material of construction cast iron ✓40 PVC _ other )explain) Distance from private water supply well or suction line �i�_ D ameter / Comments (condition of joints, ve ring, evidence,of leakage, etc.) l �S � � 7 'C / L. • � t SEPTIC TANK: lyt � !locale on site plant Depth below grader ,material of construnion: concrete _metal _Fiberglass _Polyethylene _other(explain) ii ;ant, is metal, list age Is age confirmed by/Certificate of Compliance W (Yes/No) D,mensions Sludge depth. r� Distance from topW sludge to bonom of outlet tee or baffler Scum thickness Distance from top of scum to top of outlet tee or baffle:� � D,uance from bonom of scum to bonom of outlet tee or baffle How dimensions were determined: 1 -42,&rJ Comments (reCommenddUpn for pumping, condition of inlet rid outlet tees or baffles, depth f liquid level in reta on to outlet mven, sir, c..ra, ` ' r �ntegriry, evidence of leakage, etc.) S' lS C / f ) ; GREASE TRAP:� f (locale on site plan) Depth below grade:/U0 material of cons(runion:4//_l concrete A64metaIALr<Fiberglass N,*Polyethylene4,Ather(explain) Dimensions. Scum thickness: Distance from top of scum to top of outlet tee or baffle: . 1i" Distance from bosom of scum to bonom of outlet tee or baffle: lel1 Date of last pumping: Comments (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, strut rz ntegory, evidence of leakage, etc.) rrzt4 IS T T (r•vi.•d 0t/15/91) V&g. 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 120 North Bay Road Osterville,Mass . ( Oyster Harbors ) Owner: Robert Depasqua Date of Inspection: 1 2/9/9 7 r TIGHT OR HOLDING TANK:&VL)�4Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grader Material of construct ionAgconcretWe4 meta l,CZ14ibergIassoLlkPoI yet hylenee) -other(explain) �N Dimensions: 44 Capaciry: k14 gallons Design flow: ) gallons/day Alarm level: Alarm in working orderq/� Yes;. No Date of previous pumping: A;A Comments. (condition of inlet tee, condition of alarm and float switches, etc.) -AJ 16-' 40 r- DISTRIBUTION BOX:z (locate on site plan) Depth of liquid level above outlet inven:�(� Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) 07 z5 PUMP CHAMBER:/ , (locate on site plan) ,, Pumps in working order: (Yes or No)N// � Alarms in working order (Yes or No),2N Comments: (note condition of pump chamber, condition of pumps and appunenances, etc.) r (revis•d 04/25/97) Page 7 of 10 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 120 Noth Bay Road Osterville,Mass . Owner: Robert Despasqua Date of Inspection: 12/9/97 SOIL ABSORPTION SYSTEM (SAS): .locate on site plan, if possible; excavation not required, but may be approximated by non intrusive methods) If not determined to be present, explain: Type, leaching pits, number: leaching chambers, number: leaching galleries, number. , f leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: de- Comments: mote condition of soil, signs of hydraulic failure, level of ponding, con ition of vegetation, etc.)•. 7 S' \ L CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to Met invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool. _r b Materials of construction: Ci indication of groundwater: inflow(cesspool must be pumped as pwi of ins a ion) - 4 A' J r ��� !i(�TD s, � /�T 1�s ,cruv� � Comme is (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:/` ' (locate on site plan) materials of construct n: /lid/fir Dimensions: /fXr Depth of solids: Comments: (note condition of soil, signs pf hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page a of 10 O•NEIL AGENC)' 5087782314 P. 02 (, TOWN OF BARNSTABLE .LOCATION 120 .NORTH BAY ROAD SEWAGE # !VILLAGS ntTFavn iE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. ELLIS BROTHERS CONST 362-6237. SEPTIC TANK CAPACITY 4 S-0 U LEACHING FACILITY:(type) ( Ji ,/ir TL (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER/�&&oG BUILDER OR OWNER - DATE PERMIT ISSUED: /„ - //. � DATE COMPLIANCE ISSUED: VARIANCE<GRANTED- Yea No b A r Fr vyp,� O•NEIL AGENCY 5087782114 C, TOWN OF BARNSTABLE LOCATION 120 NORTH BAY ROAD SEWAGE # !VILLAGE ntTFRv13 I F ASSESSOR'S MAP & LOT INSTALLER'S NAME 6 PHONE NO. ELLIS BROTHERS CONST 362-6237 SEPTIC TANK CAPACITY L,�S-0U LEACHING FACILITY:(type) G,�A, 3r��/��- NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER/�ae,/G BUILDER OR OWNER i /r,s,s, ,-A! DATE PERMIT ISSUED:_ 14 - (o -71 DATE COMPLIANCE ISSUED_ VARIANCE:GRANTED- Yea No U R ' O2 7 rr++ (asnoy ota?�wAlddns /alert�Dij�qnd a, y albbl) .00 M silaM Ile ale)ol s,l,ewy) Jo s ,ew u uauew,ad ow Ise YO!=� Ww31SAS 1Y508Sl 3�dM3S 10 HD NS ..----. ... _. UO,I)adsvi 10 aIPQ 'au-0 ssa,ppy juado,d (panuiluo)) N011'rW2101N1 W31SAS 121dd Wb03 N0103dSNl W31SAS 1VSMIO 3DWA3S 3DYmn59rfs -- O•NEIL AGENCY 5087782314 F. 01 TOWN OF BARNSTABLE .LOCATION�•2 O N � SEWAGE I VII LAGS e 6 CX ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPnC TANK CAPACITY LB¢CHINO FACILITY: (tYP0 �dZ4f (siu) ISO.OF BFDROOMS BUILDER OR OWNER AZ- PF,RMrrDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility � � ��� ��` Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet_ on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(if any wetlands exist Feet within 300 feet of leaching facility) Furnished.by C c � 33 . h� i - SUBSURFACE SEWAGE DISPi SYSTEM INSPECTION FORM ) C SYSTEM INFOI: . ION (continued) Property Address: 120 North Bay Road Osterville,Mass . Oyster Harbors Owner: Robert Depasqua Date of Inspection:12/9/97 lei �11JF1�75 0 lu �c .X��vsu ���,o i�i i r Depth to Groundwater Feet p, G �r Please indicate all the methods used to determine High Groundwater�12 ation: --Z/Obtained from Design Plans on record observation of Site (Abuning property, observation hole basemtnt"simp etc.) �termine it from local conditions heck with local Board of health Check FEMA Maps Check pumping records /heck local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater-Elevation. (Must be completed) Used Ground Water Contours Map., Gahrety & Miller 12/16/94 Prepared by Information Systems Department Geographic Information Systems Unit (rovia.d 04/25/97) Pac of 10 y,rr.-„•.—n.,i—.•*,—„rr.—rrr.n.s...T,n.rsr..rr.r:•.,.•�•..a'r:,,r-<,T...,r-,•u r.a�,,,er..s-i. .. _ TOWN OF Barnstable BOARD OF IIEALTII SI111SURFACF SFWAQF DISPOSAL SYSTF,M I NSI'FCTION FORM - PART D - CERTIFICATION �- �...�.».7..•.•.,.•-�.f l �.�.T1.T.TT'R."1Ti l"ST.T."TTf]T'T'.r�•.•I„'tITR'7 TRTIr�T',1'nAfiTl'ST'fO�TiTTi'T7 rsm n�*nre.rtrr.,rr.r�.—.rrrr--. —. -TYPE OR PRINT CIXARLY— P/IOPERTY INSPECTED STREET ADDRESS 120 North Bay Road Osterville,Mass . Oyster Harbors ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Robert Depasqua PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Sgrr -Inc. COMPANY ADDRESS Box 66 Centerville,Mass . 02632 Strevt Town or City Stat• 11P COMPANY TELEPIiONE ( 508 ) 775 - 3338 FAX (508 ) 790 - 1 578 .Z A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and v complete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . :Check ne ; System PASSED Conditionally The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* \ The inspection which I have conducted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Date 12/9/97 One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the DOARD OF IIEALI'll. * If the inspection FAILED , the owner or operator shall upgrade the system within one year of the dote of the inspection , unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd ,doc Y' Ld ti ss byY 3/�l� THE COMMONWEALTH OF M.A.SSACHUSETTS DEPARTMENT OF ENVI[RONMENTAL PROTECTION BE IT INN O WN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualificatigns as required and is hereby authorized to use the title CERT + i D TITLE S SYSTEM INSPECTOR as provided in 310 CMR 15_340 and Section 13 of Chapter 21A of the General Laws_ Issued by The Department of Environmental Protection_ )UrK a ins - Acting Uircctor of the i ion of Walcr Pollution Control TOWN OF BARNSTABLE I; 2GA ON47 0 41QR?& RA� Re& SEWAGE# VILLAGE C_ 6 s e ez /7/4e A.S ASSESSOR'S MAP&LOT _ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ®C� LEACHING FACILITY: (type) zd rx l�� (size) NO.OF BEDROOMS— BUILDER OR OWNER Lit 4/,4 i$.er� PERMIT DATE: COMPLIANCE DATE:. Separation Distance Between the: e> Maximum Adjusted Groundwiter Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist ��F ` on site or within 200 feet of leaching facility) ` /� Feet Edge of Wetland and Leaching Facility.(If any wetlands exist v within 300 feet of leaching facility) (0 Feet Furnished by .T`/� /m .4.0 ©'en -e& t o� ? 1 it xa _ . 040 Jr �6/ a 33 �� r DATE:_ 9/.1.4/95 PROPERTY ADDRESS:_,120 _North Bay Road Osterville ,Mass . O.H. _._ Oyster Harbors Mass . 02655 On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 1_-1500 gallon tank. 5 . 1 - line leaving cesspool to 2.. 1 -Distribution box. another leaching area . 3 . 1 -4' x35 ' Leaching trench. Appears to be inside of large 4. 1 -61x5 ' block cesspool . schrub. Based on my lnS:�Pctlon, I certify the following conditions: 1 . This is a title five septic system 2 . The &ept'ic 1. system is in proper working order at the present ti t,,ie . 1 j `The grey water 1 r-om, .-fash. si,-OI s and the fee'C{ /LI1'l;O �11� CL c e, )COI 8.Y1d "'�_eaCI,1r� �! E? ,3��_� cesshoo . f Name : J . P . 1 aco!„})(1r Jr- Company: J . }'_�1ac0„)} -- - - -- - Fc :E0 13 *met THIS CERTIFICATION DOES NOT C0'1:3-rI6!J1_E A GUARANTY OR WARRA � 9 g F r a i .. L;.fv:• } � 'a,it F f�i t}� I nn YG`'sifl ��l:'8( i.Ui'1tl8i:llU�fi t� P.O. Bc);i 36 lven:erv`i e, MA 02632-00r?6 / y THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) m A- , 1� DATA S06 ',u - /n :'A Ava.r e5 dI " P` ' 120 North Bay -Road :Oster.vil•le ,Mass . Oyster Harbors C wnar ' William Martin Done cf bn.'.ooni�. n 9/14/95 TART A - Ciicc if the following hLvc 1>,_ ._.. _ un__ . -- Pumping infUr ,Ati.va won ewquusvwj of the owner, occupant; ankLodri of _None of the ysro, co:: pwn_nv :, have beun pumped for at least two weeks amo rYe pyqlpm7has been receiving normal !' low rates during .thdt A period . Large volu&_, a: water have not been introduced into the system recently or as part cf uhis inspection . Asnbuilt plagw..hive bwen c• tamed and examined . . Note if they: ore not available with _ � N/A . nZlhs rae;1, t„_ o., `i1 :. _ ., in p-ctc:c.i for signs of sewage back-up, T.f:e site .:as in.s:)C:=nt . to:: qns c. breakout . --,1/� A> > S�{5L('::� "F��:".�C :y: �L1�/� :, . � •` .S •':eve been located on- tje;, - The septic tank manholes gore uncovor0t , opened, and the interior of *� the„•septic .ta.n�, was i.nspq cued for condition of baffles or tees, : mateKhl of 'coristyuct:ion , dimension's , depth of liquid, depth of sludge , dept.:, of mac.:;:" . The size and 1ccat._ :„ Of Lnn SAs ca in site has been determined based on existing j,_ o_mj _ _ Dn cc appycAnivajby non-intrusive methods. _/ The facility owner ( .n_ J c_:w. _ an' , i_ different &Fqm owner) were .,'' provided with _ or.. ,zjon an hepropu_ :;laipvpupnc .•.of SSDS . ;.; Recommendations . 1 . Septic tank cover on outlet end should be raised. 2 . Distribution box cover shoul be raised. 3 . Grey water cesspool should be pumped. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS: ' Y If residential number of bedrooms number of current residents e garbage grinder, ye-s or no �S laundry connected to system, yes or no -� seasonal use, yes or no If nonresidential , calculated flow: ` Water meter readings, if available: 1Q95 1� 7 Last date of occupancy GENERAL INFORMATION Pumping records a d source of informatio _T11 _A4Q System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping : Type of system Septic tank/distribution box/soil -absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) Approximate age of ,all components. Date installed, if known. Source of inf ormation;:. XT- o X - 7 Sewage odors detected when arriving at the site, yes or no l 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: /b C'•,1&4) /Aar (locate on site plan) �� depth below grade:_ material of construction: concrete metal FRP other(explain) dimensions : % ' 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 bottoip of scum to bottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendatJ�' o/n�s for repairs, etc. ) J J T' T �f! 1 r r J..Z. ' /. :; 1 1 , '` 7,[' i 6 , 1<��� , �ro y 6,, iC C-1ov1 b�r DISTRIBUTION BbX:_z / (locate on site plan) /Z16) depth of liquid level above outlet invert Comments: (note if level and distribution is equal , evidence of solids carryover, evidence of leakage i to r out of box, reco�mendation for repairs, etc. ) PUMP CHAMBER: (locate on site66plan) pumps in working order, yes or no Comments : (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc. ) 10 SUBSURFACE 6EWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYS'1'!::r^`. TNFORHATION continued SOIL ABSORPTION SYSTEM (SAS ) ( locate on site plan , if possible ; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain : Type. leaching pits and number leaching chambers and number leaching galleries and number leaching trenches , number , I-ength leaching fields , number , diiiiensions overflow cesspool , number d Comments : (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation;, recommendations for maintenance or repairs, etc. ) CESSPOOLS ( locate on site plan) : number and configuration depth-top of liquid to inlet invert 1�J` depth of solids layer �) depth of scum layer dimensions of cesspool y` materials of construction C �iG -ice 1tiet1( indication of groundwater inflow (cesspool must be pufiiped as part of inspection) Comments : (note condition of soil , signs of hydraulic failure, level of ponding, condition of egetation, reconunendations for maintenance or repairs, etc. ) /, c jM _ , 77 i L� .�0;41 ' e F PRIVY : ( locate 6n site plan) materials of construction dimensions depth of solids Comments : (note condition of soil ,. signs of hydraulic failure, level of ponding, condition of vegetation , recomaienda-tions for maintenance or repairs, etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE(_,TION FORM PART B SYSTEM INFORMATION CONTINUED Sketch of sewage disposal system; Includes ties to at least two permanent references landmarks or benchmark Locate all wells within 100 ' � E� lC3l I .�a s � T i Depth to ground water - depth groundwater Method of determination or approximation 0j,)#E . - c�-r# /6' / c c D ` �j��' � 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM 'INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) U Backup of sewage into facility? Discharge or ponding of effluent to the surface. of the ground or surface waters? Al-6 Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? _Q Required pumping 4 times or more in the last year? number of times pumped _ 0 Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: A ? below the high groundwater elevation? within 50 feet of a surface water? _-LLlwithin 100 feet of a surface water supply or tributary t water supply? PP Y y o a surface °`. within a zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh- (cesspools and .privies gnly, not the SAS) ? 4,/0 within 50 feet of a private water supply well? Al 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 anal, for coliform bacteria, volatile organic compounds, ammonia nitrogen-- and nitrate nitrogen. ' - ' - TOWN OF Barnstable BOARD OF HEALTH ( SUDSUKFACP 3%KASK DISPOSAL SYSTEM {NSYFCT/0N FORM - PART D - CCD7lFlCA?[0N __ _ � -r,pc on pmxr CI,s^nu- PROPER]'Y INSPECTED STREET ADDRESS 120 North Bay Road Osterville Mass . O.H. ASSESSORS NAP , BLOCK AND PARCEL # ONNED/ n NAME Willipm Mp `tjr NAME OF INSPECTOR ' COMPANY NAME J . P.Mac omber & Son Inc , COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( ) �O8 790 - 1578 CERTIFICATION STATEMENT I certify that I hav'e personally inspected the sewage digpoo�l system at this address and that the information reported is true , accurate , and complete as of the time of inspection . The inspection was performed and any recommendations reg-mrding upgrade / maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : ' � X _y y y3yotem PASSED ' The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or, the. environment as defined in 310 CNR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . * System FAILED The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 ' 310 CND 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . ^^'~'"^ ^"^ "^a"at"c One coPY of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the 130ARD OF HEAL'I'll. * If the inspection FxzLoo ^"— ' within one reur of the^ dot ' �h*� the or opor«�»r shall upgrade ' the o�n��m e o inspection , unless allowed or required otherwise as provided in 310 CMD 15 . 385 . ` Dactd.duc ^ -�� Cc=cnwearn cr Mossc�^:dens Execurrve Office cr Enwor entc,httc.a D eP artment of Environmental Protection ' Water Pollution Ccntrol Tecraccl As&wcnce and Training c.ections i wuwm F.wow Trudy Cos• • SwwY.EOEA • Thomas B.Pow.n • xar+q Carn+rcnr 06/12/95 i ATTN: Joseph P. Macomber, Jr. Joseph Macomber and Son PO Box 66 Centerville, MA. Q2632- Dear Joseph P. Macomber, Jr. , _ I am pleased to inform you that you have attended training, met the experience qual.ifications4j-,and have passed the Title 5 System. .`'... ! Inspector exam, pursuant to 310 CMR 15.340. The passing grade for . the exam was 39/52 or 75%. This is an official notification that you are a Certified Department of Environmental Protection System Inspector pursuant to 310 CMR 15.340. You will receive a System Inspector certificate at a later date. If you have any futher questions, please write to me at the following address: Kimball Simpson D.E.P. Training Center 50 Route 20 Millbury, MA 01527 Thank you very much for your time and consideration in this matter. Sincerely, Kimball T. Simpson, DEP Training Crater Director [24051 _ ... ue m. FAY En.&?5SS92-U • T®lounans 508.756.7:81 Water Conservation SAVE Tips , ME! CHECK FOR LEAKS Water Loss in Gallons Due to Leaks Leak this Loss Per Day Loss Per Month Size • 120 3,600 • 360 10,800 ° 693 20,790 ® 1,200 36,000 ® 1,920 57,600 ® 3,096 92,880 0 4,296 128,980 ® 6,640 199,200 Aft 6,984 200,520 8,424 252,720 9,888 296,640 11,324 339,720 AdUL 12,720 381,600 14,952 448,560 TOWN OF BARNSTABLE (LOCATION J,20'-`NORTH BAY ROAD SEWAGE # 3 ' a� (VILLAGE n_STFR11T1 I E ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. ELLIS BROTHERS CONST 362-6237 SEPTIC T NK CAPACITY C LEACHING FACILITY:(type) ®fir (size) 3rx*ell, NO. OF BE,DROOMS PRIVATE WELL OR PUBLIC WATER/`a4"e. BUILDER OR OWNERS fCL ,;. DATE PERMIT ISSUED: v DATE C r MPLIANCE ISSUED: r VARIANCE GRANTED: Yes No %'� _A41A/7- � I C-0 J 213 GP9 � �Q P166 � 1 o � � 6 601 .THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �xnatable TOWN OF BARNSTABLE Diivnaal Works Tonstrurtinn Prrutit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: 120 North Bay Road, Oyster Harbors,Osterville Map 72, Parcel 28-1 ................_--.............................................................................. ----------........................---......---......----------------------------------•----....... William Martin Location-Address 189 Elm Street, Sor % tmouth, MA. 02748 ----------------------. ......--------------....... -------------.---------------------------. .............. '- O ner Add erss ----��s.---- ...� =--_�..�...._._s:�-............�...._ ..................... �'...� .:.. Installer v Address %/ f Building 61 K55 Q Type o i d g 4 Size Lot....... ...................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building No. of persons............................ Showers YP g ---------------•------------ ( ) — Cafeteria ( ) dOther fixtures ------------------------- .........................................--------------------------------------------------------.....-----.............__. W Design Flow ..110.._.. ------_.� gallons per ` i day. Total daily flow 44Q Ions. W Septic Tank—Liquid capacity__1`3. gallons 4� ength_8 r_5_._.____ Wid 35 5__._..._. Diameter................ — pOth-. ------ 21 x Disposal Trench—No._..t...........:... Width............._..__.. Total Length.....:............_. Total leaching area.........._.........sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( X) Dosin tank ( ) Percolation Test Results Performed by---�hris Jolly " _______________ Date.......6�8�93 r a Test Pit No. 1...............minutes per inch Depth of Test Pit___4 5 Depth to ground water 4.5 LL, Test Pit No. 2... ......minutes per inch Depth of.Test Pit ................. Depth to ground water....no _water �i T .............•---------------•--•-------..I---•--•-----•r----- ................_._............. Description of Soil_._.___0 ___-__3 __Top and Subsoil- 3 - 12 medium light sand ----------------•--•----------..._.. x W VNatu e of Repairs pr Alterations—An§wer when ap 'cable_______________________________________________________________________________________________ Replace existing cesspools with new T1 e V system Agreement: The undersigned,agrees to install the aforedescribed Individ I Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code e undersigned further agrees not to place the system in operation until a Certificate of Complianc as be i ed by the b / f health. Signed .... .. ........ .. - - --------- -- Application Date Approved B ! - 1 PP Y ...-... - . �_ �Q Application Disapproved for the following reasons: ..................................... --------------.............................................................. ...............--------------------------------- --------------------------------- ---------------------------- ---------- --- ---- -------- ------------ -- -------------- ------------ ....................................-- Permit No. ----...�..�......... .. Issued ---------....... --------------'-'-----Date------'---....---.-.........to..... No.._.�. �2 Z0 F; FuB........1. ....... r• THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ppliratton for Disposal Works Tomitrortiort ramit Application is hereby made for a Permit to Construct ( X) or Repair. ( ) an Individual Sewage Disposal System at: 120 North Bay Road, Oyster Harbors,Osterville Map 72, Parcel 28-1 ................_................................................................................ ----•••-•-•••••-•.....---••-......••••--......----•••...........------.............•-•-•-•-----••• William Martin Location-Address 189 Elm Street, S.r mf%.-rriouth, MA. 02748 ......................- ...............-----------------•-----....... Owner Address Installer Address UType of Building 4 Size Lot..! 85______________Sq. -feet t-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QOther fixtures ------------------------------ -• •-••---•--•-•••-•••••----•••••••--••---•----•--•-----•••••••••••---•....-•--...••-•--•••....--••-._........._:.. W Design Flow..................................... gallons per pe o FeeR day. Total daily flow_______-._.._.__.._................._.......gallons. 110 440 WSeptic Tank—Liquid capacity___ allons Length: t 5___._.. Width...V 5______--- Diameter................ Depth......0__._. x Disposal Trench—No..._1.............. Width.......4........... Total Length....35.-......... Total leaching area.....2.8.......sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) o '-' Percolation Test Results X Performed by._..Chris Jo11V__---?-*BD6 1 6f 8/93 •• ---... Date_._- -••• -••-••••••••••. a' 4 5 � 4 5 0.._... Test Pit No. 1......'--------minutes per inch Depth of Test pit_........4---------Pit Depth to ground water....no water W .......................................................... _ _ P _ `rd O Description of Soil........9'____- 3' Top and-Subsoil; 3i - 12' medium light.................................................. and x ---....---•----- ..................................................t x •-••••-.....................••••---------•••••-••--•--------------------••.........-----••••.--•--•---•••-••••------•------••-••-••--•----•-•••...•---•••-•-•••-•-•-•--•--............•-•-•--••-•-_... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ Replace existing cesspools with new Title V_system Agreement: The undersigned agrees to install the aforedescribed Individ 1 Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code e undersigned further agrees not to place the system in operation until a Certificate of Complianc has bee is ed by the bWoo health. 9 Signed .. ... `---..-- .... - ............. .--. Date........... ... A lication Approved B Y., .�,� ...=-,-- '' 1 ' PP PP Y �:... -- Application Disapproved for the following reasons- ----- ---------------- -- -- - ------------------------------ ---------------- ------------------..........------- ------------------- --................. --- -------------- --------------=- r� Dare PermitNo. - 0'.....----- Issued -------------------------- -------------------- Date f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Terttftrate of CZompliana . THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( X ) or Repaired ( ) by.... ............�—��C�C.-1.�s.--- n..S. ':-.....C_. ... ......................... Installer It at --..--..120..North Bay Rd.., Harbors, Osterville, MA. -. ... ------------- --- ----------- ----------- --------------------------- ---------------- --------------------------....................... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ....... .- ,. .Q..--.... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION GSATISFACTORY. i DATE--------------- ----F. f "�j 1._ 7................ ....................... Inspector ......... -�. ............................................................. I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No....p?,�� - F TOWN OF BARNSTABLE ED._ .�� ............ Disposal /o/rkii Tondrudivit ramit. Permission is hereby granted........ L ....... ...... to Construct ( t). or Repair ( ) an Individual Sewage Disposal System at No....120._No :th Bay load, Oyster Harbors, Osterville, MA.. . ......-. - - Street qq as shown on the application foWDispo 1 Works Construction r it No._..3.'_, ated.. . . . ......... ............ Health DATE-••--•............••-••••.•.•. .. ---•.... •••........... FORM 36308 HOBBS 6 WARREN,INC.,PUBLISHERS i SLAB EL @ 14.8' SEPTIC PROFILE TEST HOLE LOGS C.I. COVER TO GRADE (NOT TO SCALE) ACCESS COVER (WATERTIGHT) TO ENGINEER: AH OJALA, PE Q� r WITHIN 6" OF FIN. GRADE 2' DOUBLE WASHED PEASTONE DONNA MIORANDI, RS �P 14.0' MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 14.0' WITNESS: I 'LOCUS DATE: MAY 25, 2000 12.8f FOR FIRST UN PIPE LEVEL 11.03' PERC. RATE _ < 2 MIN/INCH PROPOSED 1500 m l 1 GALLON SEPTIC 11.5' o o L W . " ® ® 2 s' 18• CLASS I SOILS P# 11.75' TANK (H- 20 ) GAS 10.49/ BAFFLE 10.74' «�� 10.57 00 2.5' 96'® ® ® 9.53' z 00 MIN ( 2 % SLOPE) �6" CRUSHED STONE OR MECHANICAL H-20 FLOW DIFFUSORS gR1DGE ST. COMPACTION. (15.221 [21) 3/4' TO 1 1/2' DOUBLE WASHED STONE 4 ELEV. 2� -k DEPTH OF FLOW = 4 MIN 0"( 1 %' SLOPE) ( 1 % SLOPE) 9`g ' TEE SIZES: A INLET DEPTH = 10 O LOAM OUTLET DEPTH 14„ 5 3� 14 1OYR 3/4 LOCATION MAP E FOUNDATION— 13' SEPTIC TANK 69' D' BOX 10' LEACHINt' MS ASSESSORS MAP 72 PARCEL 28-1 FACILITY 18" 1OYR 7/2 ZONING DISTRICT: RF-1 SEPTIC DESIGN: (GARBAGE DISPOSER IS NOT ALLC WED ) Bw YARD SETBACKS: DESIGN FLOW: 2 BEDROOMS ( 110 GPD) _ GPD LS FRONT = 30' USE A 220 GPD DESIGN FLOW ADJ. WATER 0 3.6' 32" 10YR 4/4 SIDE = 15' LOT264 SEPTIC TANK: 220 GPD ( 2 ) 440 REAR = 15' - USE A 1500_ GALLON SEPTIC TANK C PLAN REF, LCP 15354 W LEACHING: MS FLOOD ZONE: C, B, A11 EL, 11 L.C. BOUND EXIST. TITLE 5 SEPTIC SYSTEM FOR DWELLING AS PER FOUND INSPECTION REPORT BY J.P. MACOMBER, SEPTIC AA' _ (1 + 29) X (1 + 9) = 300 SF 10YR 6/6 INSPECTOR, DATED 2/26/00 (SEPTIC SYSTEM PASSED) LEACHING TRENCH APPROX. LOCATION ONLY 300 SF (.75) = 225 GPD WELL: 29 _____ 7.6' 0 oes. WATER 2.3' ZONE: A A UTIU Y 4' - -" •"' ."." • USE 3 FLO DIFFUSORS WITH 2.5' STONE ALL ' POL ADJ: 1.3 AROUND OAK 86 f - D fM�E NOTES: O 1 '1 HOLY / A I;GLLY 1 D/',TIIIVI IS � t .. _ _. ... _ ,. 2. MUNICIPAL WATER IS XISTING A 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. 1h ~ti3�� 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H-10 & 20 z' 5. PIPE JOINTS TO BE MADE WATERTIGHT. L ')2 LIG T II 3 TOWN AND STATE ASTAL 0 POT 0I/ BANK AT TOP OF WALL q�)� 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCL WITH MASS. �w» H Y , COBBLESTONE ,, ,' ; ;'` ,� ENVIRONMENTAL CODE TITLE V. `` I ARKING I / ''` ..f NORTH BAY 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE Y I , SILL (� A C. A M LA El BLU �•., I i r i s:i.4i:'v ... 2'.. E',' Yo AZ USED FOR LOT LINE STAKING.�, f r r v I 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4„ PVC`. B• NE ` ` �� p'�R C:{' 4`PSI r 9. COMPONENTS NOT TO BE BACKFILLED OR COt CEALED WITHOUT \ r . . m y ;' , ' INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED SL :a� I:'�r�`F:LI- w j j 3 l FROM BOARD OF HEALTH. ;w : 9� 14 ` 1 ; i' PATIO - .i , SPA EXIST. � yQ• I '-•!' UTILITY R ; POOL Qy �Up POLE INE AP. MAP i,l - �2�� 4�3 CS dye i' I EOGF OF PL N7 A EA %( qAk MARlH GRASS LEG END TITLE 5 SITE PLAN , PK NAIL ' ` .FLAG$T®NE. /LIGHT " .,««KKK ��,',� 1 .'AREA 100.0 PROPOSED SPOT ELEVATION ( DST o�. OF #120 NORTH BAY ROAD Eoulo ARE TOWN AND PROP POOL END OF 10OX0 EXISTING SPOT ELEVATION WED ', r sT• * STATE EXI FOOTPATH 100 PROPOSED CONTOUR IN THE TOWN OF: PA` DRI D sl EXIST. TARS cm ROCK R 0 .6 BANK GAR/STORAGE N Ew fENC TO MAT ; (OSTERVILLE) BA R11�'S T A BLE NGNDp OPA E do EXIS71Hc W DE51 PREPARED FOR: MICHAEL AND MAUREJN CHAMPA \� \� " SLAB °`�'� ( / 100 EXISTING CONTOUR RH f REMOVE EXIST J ELEV=t4.82' , �cc^^ CJ DECK / i` FENCE I EDGE OF Q � PLANTED AREA , BEACH H \ � STARS SHRUB 0 ---• -- 14' DIAM FLA POLE a L+RGE AK��1} 30 30 60 0 90 PROP, 25' 0' DECK H GROIN BOARD OF HEALTH 10' DIAM APPROVED DATE MA SCALE: 1 = 30' DATE: JUNE 1, 2000 �SHRU PROP. WORK LIMIT LINE OF STAK SILT FENCE REVISED 9/19/00 (STAIRS, FENCE, WALL,ST) \_=..ter \1 14" CE GP�1 EXIST, GARAGE/STORAGE WITH PROPOSED SECOND FLOOR 2 P�P` NUKE BEDROOM ADDITION (WITHIN EXISTING FOOTPRINT) Qfv off 508-362-4541 fox 508 362-9880 UTILITY RNp �QQP �tV`H Of POLE '• ONO Q I �P`\11 Ut Mq1 J M '*9 down cape engineering, in c. ���� A H.E 9�yG ��� oJALA. ❑ 10' EVERGREENS » ELEC METER TWIN - 1' zz ON POST ; , , naL4jj FENCE _�* CD OJALA CIVIL206 f CIVIL ENGINEERS 9 IN .2 348 No.30792 3 ,- ;-`---• LAND SURVEYORS ��s�of rER`S d,��fi `\ s �srEa�' .. 'FENCE ' AL 00- 126 LOT 939 main st. yarmouth, ma 02675 ARNE H. OJALA, P,E., P.L.S. DATE Osterville Grand Island Revisions: 20 /9 18 17 16 3 DAIS DEMPYIOI'1 PREN7ISS // / // / 15 14 1 12 7 / "O / / // // // / a, I I I 5 3 No End Post And Rail Fence / / I I f 4 / 2 t a Ba / / / // � � Old e � o � CB/Found 20 21 21 Existing Cesspool To Be � / / / / / / �� I I I 12 13 14 15 16 17 18 19 r / Pumped And Filled / / � , 11 1 I I I f I / h srt L!/►e / Pbst Anc�Rail/F ice / / I I I I o r �°d• 10 I / / — _ _ I Proposed 35'L x 4'W, x 2'D7 Septic Manhole 9 eaching Trench 8 1 I \ Zoning Setback Uf!llty Pole I / \ I_ \ 7` / T / l / St n l o e 7 \ I \ / HV C Unt / Proposed Spa, dt D*ck / / J °"' Scale. 1"=2083' CB/Faun d` o� e / \ A / / l \ , <1J I I He�g s / \ I '� DECK / / / / / / / / / / l Assessors MapLocus72Parcel 28-1 References: (T real)I \ l\ \ / � / / / / �IIJc. \ Y 06 Land Court Certificate 114597 \ \ ( \ ( \ \ Proposed 1,500 / /. fj ��tJ / I I I I I I \ ( \ `� \ Septic Tank \ yOP f / / w sho°,r / Zone RF-1 1 V) / l Fixed Land Court Plan 15354W \I \ �\ \ \ \ / / / / Blank alk Timber Pier Ei= 5�, ° ' ,. / ( Min. Lot Frontage 20' SF \ Y I \ 1 \ \ \ \ 4 PVC / / / / / l / I stone \ Mln. Yard Setbacks: License Plan No. 5416 Dated Sept. 25, \ \ w I I I I I \ \ 20 )�oposed Brack w I l l 1 I / I o0on Groin 1968 \ Watergate EX� I I I \ \ \ \ cn\ D—Box 0 10' P/ontii�gs / ' / / / / I / I I oo Front 30� trn I 1 1 i Slde 15 w9 �wot�.•il e I I \ \ \ 19 \ � � � Mjn' L L L L L L L L W �' � l l 1 1 � I j l I �- � Rear 15' \ 1 I I 1 I I 1 \ ° \ 4'PV �� ,LLI_L I- l / / / l / I I / s5 \ I I ' I 1 w , 1 18 Ll ht P le Step ,c;F_ \L n2o° ° L W W W / / / / // ll /l 11 I l I ��o F.E.A�I.A. 100 Year Flood El. 11.0' g Proposed Addition—� •—21.1 L L L L L\L w dawn W l / / l l / i l l o f 5r L L L pt 12' Piles \ I I I I 1 16 �\ \ 1 L\L\L W W / / / / / / / I I O (Typical) 15 \ k, 1 \ on tin S I-L W / l l l 1 1 1 14 \ \ \ LLL�L �-L- 20.7 #12p EXis �\ \ \ \ \ 13 s t #2 \ �LLL t/n9 \ \\ \ \ \ \ 12 \ \ \ \ \ w Proposed edroom \ \ r , d 4 B�-oO�loo \ 18 17 — I Stone walk 18.2 n"1 \ 16 15 14 13 / l`t i / o I �' I �� ° Project Title: \ >\ \ 10 \ \ \ \ \ \ \ \ \ / 12 11 10 9 8 I J I F1 ain / / l l l l ° ro I I I \ \V A \ V A V v A \v A � p�sed Addition l \\ \ \\ \ \ \ \\ \\ \ /\ Prdposjd D \ ti on'orete Wall • \\ -- \ \ \ \ \ \ \\ \\ \ I� r°r Gar 9e ° Picket F7Ce / / / l / /l l \ y. \ 120 F/o o - Pr�s/ed Addition / / / / l \ t \ E - f? Ba Hyrlron t ,�1702 \\ \\ \\ \ \\ �P`'�� 7s.5 Ligh t P / / / / / // / l !l \.\ \\ rag Bolt El.=8.91' N.G.V.D. \ \\ \ \ \ \\\�er9 \ \ \ 15/ i 3 ARood ptility Po, 14 Hedge \ \\ \\ - o�„ \ ch Bamstable (Osterville) \ I o 13 12 � / Hedge z I'll X I Mo. \ \ \ \ 11 Z / Flog Pqle \ \ 10 \ 1 \ 1 \ •,c� � � � � Ex�g Cesspool To!fie I Purrped And Filled/ 6' PREPARED FM Test It #1 ce , Fen 1 13 2 1 NOTES ��1C1/?'1 ll�la►rfle7 Trough 4' P/'cK ° Land Court THE PROPERTY ONES SHOWN HEREON WERE COMPILED � g / ACTUAL SURVEY ON THE GROUND.OM PLANS Or' RECORD AND DO NOT REPRESENT AN \ � i - - - _� Bound Found -15 CB/DH Fn d F (24' Down) ELEVA TIONS ARE BASED ON N..G V:D. Wood\ \ \ / 5 / Shed 911 M f n Sauget \ \ Utility Pole W/Down Guy S \ prop , A. M. Wilson Associates Inc. \ I I 508 428 1450 / FAX 420 1856 5 \ ,\t ° Top Of Foundation E1.=20.1'-+ \ � Test Pit Data Drawing Title � 4" PVC O .01 ft/ff First 2' To Be Lald Level ® •0050��� PVC \ Indicates I'ndicafes \ Perc Groundwater _ Test = _ 2" Peastone 18.2' ep is P#8069 Tank Box 0 0 0 0 0 0 0 0 0 0 0 0 0 + Ground EL=5.5 1,500 Gal. ' 16 ��4' 17.2 10 Subsurface Topsoil 17.9' 17.T �• �5 0 PI t No. _ .- 3/4' -=''l 1/2' Washed Stone J e V vQ(�e Test By. C.Jolly 15.0 Subsoil 6-8-93 Proposed Leaching Trench Disposal Test Date: 5' I 3.5 Witness: J.Dunning 35'L x 4'W x 21D Perc Rate: — - - o Design Coarse Design Flow: Notm Sand 4 BDR ® 110 GPD Per BDR = 440 GPD 1. Unless otherwise noted, all construction 6. Locations of existing utilltles are approx— methods and materials shall conform to /mote and are to be verified in the field by —1.0 Septic Tank Requirements: Tit/e V of the state environmental code the contractor prior to construction. 1.5 x 440 = 660 Gal. and any applicable local regulations 2. Precast concrete septic tank, d—box, Ground El.=16.10 Use 1,500 Gal. Tank and leaching facility to withstand H-10 loading unless under pavement, drives, Topsoil Pit No. 42 or travelled ways where H-20 loading —15.0 Leaching Facility Requirements: shall apply. Test By. C.Jo!ly Based On Perc Rate l2 Min. nch J. All pipes in the system shall be schedule Subsoil 6-8-93 Side Area Infiltration=2.5 Gal. SF. 40 or equal.Test Date: q Scale: 1'=20' — 13.0 Witness: J.Dunning Bottom Area Infiltration=1.0 Gal. SF. 4. No field mod/fications to the sewage Y, Perc Rate: CI Min. nch disposal system shall be made without Medium prior written approval of the engineer 0 20 40 50 � Light Leaching Facility Provided: and the local board of health. Sand Leaching Trench 35 L x 4 W x 2 D 5. This system Is not designed for a Date: June 15 1993 Dwg No: Side Area: 4' x 35' x 2.5 gq l F. 350 Gpd garbage disposal unit Design: C.P.J. No Water Bottom Area: 4 S F.' x 35' x LO Go/ =,140 Gad Check: ' — 4.0 Total = '490 GPD Drawn: J VB. ob No: 2.0666.0 Sheet 1 of 1