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HomeMy WebLinkAbout0052 OAKVILLE AVENUE - Health 52 OAKVILLE AVEUOSTERVILLE A - 1 1 i r f i Commonwealth of Massachusetts Title 5 official Inspection Form r� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments SDI Property Address �S O Owner owner's Name S ✓Yl/l� I/�/T information is required for every — page. City/Town State Zip Code Date of nspecti n :r. 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. %# ILI 3 49/ Important:When filling out forms A. Inspector I fo ation ' on the computer, a r� use only the tab ' v , key to move your Name of Inspector cursor-do not �(�� use the return Company Name n key. Wo /C� O� Company Address i� �� 'M //�/�/� O��� • City/Towy( � Telephone Number) n� State Zip Code N / /f/Y License Number - B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that�A=asses 1. 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspector' Signature Date 4 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. • -iJe 5 0"oai;rspee ton=onn:saosur`ace sewage Dsposal System•?age t of t8 ` ;5insp.doc•rev.7/26/2018 - • A Commonwealth of Massachusetts 9 Title 5 4fficial. Inspection Form N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6j Property Address • A100 . y Owner Owner's Name information is os4e ✓(& 14i� required for every page. Cityj7own State Zip Code Date f I specti n C. Inspection Summary Inspection Summary: Complete 1, 2: 3, or 5 and all of 4 and 6. 1) System P ses: a I have not found any information which indicates that any of the failure criteria described . in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass'section need to be replaced or repaired. The system, upon completion of the.repiscement or repair, as approved by y the Board of Health,- will pass. Check the box for"yes-. "rid; or"not determined" (Y,M N, ND)for the following statements. If"not determined,' please explain. The septic tank is metal and over 20 years oid*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): - its 5 OfS ca ra: aai irspeon Fo suosurace sewage Jisposai system-.Page 2 of 18 .t6iruP tloc•rev.7I26/2018 a . Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 17 oZ On 41W Ae- 4,/,e- Property Address Owner Owner's Name 40 information is Ile Sr-krV, � %� op 6 ss /;k-iV410 required for every page. City/Town State Zip Code Date of Inspe tion C. Inspection Summary (cons.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. , ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipes)are replaced ❑ Y ❑.N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required.by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 316 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.9oc•rev.7/26/2018 —we 5 official:rspeccn=o.m:suosurface sewage Disposal system•?aye 3 of 18 Commonwealth of Massachusetts 41. Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t� Property Address / 1 4 s I !l� -- A . Owner Owner's Name information isv` / A�f 0_6 required for every `ll/ , - page. CityRo` n State Zip Code Date of I pection C. inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a'bordering vegetated'wetiand or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ -The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. . ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory:for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ;i?, 9g ackup of sewage into facility or system component due to overloaded or ze , lo ed SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool w `tle 5 5dal'nspecticn Fo:, Subsurface sewage Disposal system•Page 4 of 18 t5insp.doc•rev.7262018 { Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form -Not for Voluntary Assessments O�1,-VI114 vim. Property Address, Owner Owner's Name / information is required for every page. City/Town State Zip Code Date w In pection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cunt.) Yes No -� 99 Static liquid level in the distribution box above outlet invert due to an overloaded �—' Y. or clogged SAS or cesspool ❑ /z Liquid depth in cesspool is less than 6" below invert Ior available volume is less ��� than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion-of cesspool or privy is within 100 feet of'a surface water supply or / tributary to a surface water supply. r / Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. , I Any portion of a cesspool or.privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis;performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] , The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. J The system fails. i have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be'considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or-no'to each of the following, in addition to the questions in Section CA. Yes No 71, the system is within 400 feet of a surface drinking water supply of a tributary to a surface drinking water supply the system is within 200 feet the system is located in a nitrogen sensitive area (Interim Wellhead Protection E Area—IWPA)or a mapped Zone Il of a public water supply well Title 8 rffca,Inspec lcn For:bubsurmce sewage D sPosal System•Page s of 18 .` i6ir,':P•Coc•rev.726W 8 Commonwealth of Massachusetts i, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 1 6 Owner Owner's Name information is required for every page. CitylTown State Zip Code Date of Ins Pon C. Inspection Summary (cont.) If you have answered"yes' to any question in Section C.5 the system is considered a significant threat, or answered "yes'to any question in Section C.4 above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes o ` ❑ 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? ❑ as 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)] s T Ue 5 O`ic lat inspenon corm:sui urface sewage Disposal system-?age 6 of 18 + . t5insp.doc-rev.7125/2018 Commonwealth of Massachusetts 01 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 4 i 14 ve Property Address / Owner Owner's Name / b information is required for every page. City/Town State Zip Code Date of lnspe ion D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): _ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description / /Sco (a/� /D H ct /Ar 1rt N/ 4 / /V/�Vf o V I/.v� �I'1 PSA6L 70 �-� �- �046c•IeH (�+�ia,^'b�rf 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes f o Does residence have a water treatment unit? - ❑ Yes CNo If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) ` Laundry system inspected? ❑ Yes No es ❑ No . Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): . Detail: ❑ Yes Sump pump? Last date of occupancy: Date .,.e 5 o_`daiinspacaon cr.Sccsu`ace Sewage Disposal System•Page 7 of 18 t5ins�.doc-rev.712612018• . ° Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 0 Owner Owners Name information is required for every page. City[Town State Zip Code Date of I specti D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available.- Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: dug ouo� 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: 16inspaoc•rev.7126120118 itie 5 o fiaai nsoa,=or.=oar:suosurface Sewage Disposal System•?age 8 of 1 B Commonwealth of Massachusetts Title 5 Official Inspection Form u Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � ( Q, OG4v/Ile AV, Property Address 11416 b Owner Owner's Name / ooc r� / J� information is �/n�n' ,?J l required for every 5 � page. CityfTown State Zip Code Date of Ins ction D. System Information (cont.) ' 4. Type of Sys / Septic tank, distribution box, soil absorption system t �u.�►�/! GG�..�l.� ❑ ,Single cesspool ❑ Overflow cesspool i ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the i/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate ageof all components; date installed (if known) and s u e of information: � l f Were sewage odors detected when arriving'at the site? ❑ Yes ,-5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction'. cast iron 0 PVC ❑ other(explain): Distance from private water supply well or suction line: - Comments (on condition of joints; venting, evidence of leakage,'etc.): 3Ue d `cal inspection Fo.�r_sutsunace Sewage Disposes System•Page 9 of 18 t6insp.doc•rev./26/2018 - i ♦ 4 Commonwealth of Massachusetts Title 5 Official Inspection Form. x b Subsurface Sewage Disposal System Form -Not for Vo luntary F. Property Address /p v 9 d Owner Owners Name information is jf �. • required for every page. Cityrrown State Zip Code Date of Inspe ion D. System Information (cont.) 6. Septic Tank (locate on site plan): �rJ Depth below grade: feet Material construction: - concrete -❑ metal d ❑ fiberglass ❑ polyethylene ❑ other(explain) s If tank is•metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate ❑ Yes ❑ No X h Dimensions: Sludge depth: V 5 Distance from top of sludge to bottom of outlet tee or baffle u Scum thickness Distance from top of scum to top of outlet tee or baffle, Distance from bottom of scum to bottom of outlet tee or baffle - ,. How were'dimensions determined? z Comments (on pumping recommendations, inlet and outlet tee or baffle,condition, structural integrity, liquid levels as related to outlet invert. evidence of leakage, etc.): R . . • hut' 4�� �es � � 00 COv� c'/774v1 A b R' - ;r -iUe 5 aa�Inspecocn=or, SCCSuraGe Sewage Disposal System•Page«io of 18 t5insp.doo-rev.7/26=18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form ie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / Owner Owner's Name information is QS.�Q X o� L� �V� J a8 required for every page. City7own State Zip Code Date of Insp ction D. System Information (cost.) " 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene - ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8: Tight or Holding Tank (tank�must be pumped at time of inspection) (locate,on site plan): Depth below grade'. Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity V gallons Design Flow: gallons per day Citle 5of`iaa'.;nspecuor Pomn:Scosuace Sewage disposal System•Page 1 t of 18 e ;Sinsp.0oc•rev.VM2018 ' k r Commonwealth of Massachusetts Title 5 Official Inspection Form �1 Subsurface SewageP Y Disposal System Form - Not for Voluntary Assessments .� L ©G Ivy tle '14� Property Address Owner owner's Name A� / information is V S �L 0 required for every page. City/Town State Zip Code Date of Ins coon D. System Information (cont.) S. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Aiarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): v- v� ifi/b Sol s ?;:fie 5 tl2i!^soxuon Fom.SUDSJr%Ge sewage Disposal system•?age 12 of 18 t5i,p.doc•rev.7252018 ` L A - Commonwealth of Massachusetts rr Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Eel ©G k" Property Address Owner Owner's Name ((O information isOho required for every page. City/Town State Zip Code Date of Ins ection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: u Y ❑ No' Alarms in working order: Yes ❑ No` Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: CeP Soo. G s ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ' ❑ leaching trenches number. length: ❑ leaching fields number, dimensions. ❑ overflow cesspool number. innovativeiaiternative system Typeiname of technology: ---- 'iue `aai!nsper�or,=cr.:SUDS�,taoe Sewage Disposal System•?age 13 of 78 tsmsp.doc•rev.7/26/2018 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. S y(//,e ��� Property Address Owner owner's Name / information is required for everyl 'e page. City[Town State Zip Code Date of l pection D. System Information (cost.) 11. Soil Absorption System (SAS) (cost.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): _ o aC',vt i He :;NJ S O—C OT 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth.of scum layer Dimensions of cesspool ' Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of pon ding,'condition of vegetation, etc.): ?ire 5 `oal in.pecton Fo.,suosurace Sewage oisposai System•?age 14 of 18 - t5insp.0oc•rev.i26/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Volunta Assessments l� Property Address /�v Owner Owners Name A/' , i/ information is S /!/! (/� required for every — page. CitylTown State Zip Code Date of Inskectiorl D. System Information (cont.) ' 13. Privy (locate on site plan): Materials of construction: _ Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): r Tine s Offiaai Inspacaon=onn Sewage Drsposai system•?age is of 18 tsinsp.doc-rev.712612018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 11140 Owner Owner's Name information is �s- ✓��lie IV A Q�G j � a g o2 c0 required for every page. City/Town State Zip Code Date of Ins ection D. System Information (cont:) 14. Sketch Of Sewage Disposal System: i Provide a vie f the sewage disposal system, including ties to at least two permanent reference landmark r benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the b ' ing. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately Ll i i i i G Spp-1 rc i T I � /QFN i I �.Nnh � � ��-� � Soo a 0� jy i i 0 � ' 91•� li I i Tlue 5 Qf"C21 i,SFnuon=cm:sut,,face sewage Disposal system•Page 15 of 18 [6insp.doc-rev-7/26/2018 r Commonwealth of Massachusetts i19 Title 5 Official Inspection Form P Subsurface Sewage Disposal System form -Not for Voluntar y ry AssessmentsI 9�,W;Fi , s Property Address Q Owner Owner's Name information is required for every ✓ - ��� a$ 01� page. City/Town State Zip Code Date of lnsp on > D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑+.Surface water . ❑ Check cellar , ❑ Shallow wells • Id Estimated depth to high ground water. feet - Please indicate all methods used to determine the high ground water'elevation Obtained from system design plans on record 'if checked; date of design plan reviewed; i Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with 'Local Board of Health explain: -7L 110le5 Ell Checked with loca!'excavators, installers - (attach documentation) Accessed USGS database- explain:; You must descri ow you est blishe/Id the high ground water elevation: F It / G✓�1, "f�1 rJeQ� 8/'�"i�i a�►o•� �t,r • � Ql�.t�' �� Before filing this inspection Report, please see Report Completeness Checklist on next page. 5insp.doc•rev.71252018 - 7ite 5�5aai insoecaonJ°o.-:Suosurface Sewage Disposal System•?age 17 0!t8 Commonwealth of Massachusetts w: Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / A1 Owner Owners Name0'r-ks"111 /bOinformation is vo!required for every /� b.J page. CityfTown State Zip Code Date of In pectin E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector?nformation: Complete all fields in this section. B. Certification: Signed 8t Dated and 1, 2, 3, or checked C. inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 ailure Criteria)and 6 (Checklist)completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.5oc•rev.7/26i2018 '::le 5 oftsaa:Inspection Fora:suosurtace Sewage Disposal System-?age 18 of 18 Town of Barnstable Regulatory Services Thomas F. Geiler,Director BASIDWABIX Public Health Division 39. Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Date: Sewage Permit# 2L'1 Assessor's Map/Parcel ' Q)Q;] Installer& Designer Certification Form Designer: C��� E �f�� Installer: A-ry C 5 4L,L.L_U, . Address: j_ Address: _ ( Ci On Jkm&� '40 L-c t-'YY,'- was issued a permit to install a (date) (installer) septic system at C` A-K_Vq LLk:� iQ IL--F 6,At-3r�`based on a design drawn by n (address) dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if required)was inspected and the soils were found satisfactory. 4_� yipOF I hn (Installer's Signatu � � HARRY ����1 EARLi' c� L.MITUY. JR. v' esi r s Signature) (Affix ere ere) Al- PLEASE URN TO BARNS ABLE P C EALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED-UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice formsWesignercertification form.doc Commonwealth of Massachusetts :.,•: .. , ;; '. ;:} Title 5 Official Inspection Form Subsurface Sewage Disposal System:Form -Not for Voluntary Assessments 52 Oakville Ave ` Property Address �-7-; - Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) +, Owner Owner's Name information is required for every OSterville MA 02655 3-28-14 page. City/Town p State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may notbe altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: A Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 r, - :! a►; t. ,�., .r r : ;; ,� Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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:,- -" i i � €-111 " - ? .4, .. ® .Passes y*.f , ❑ Conditionally Passes , + �-r❑ ,Fails ❑ Needs Further Evaluation by the Local Approving Authority t ' ,• i,; ; ` o.. 3-28-14 Inspector's Signature ' '' 3 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•3/13 .- , v• Title 5 Official Inspection F urface Sewage Disposal System•Page 1 of 17 ti A Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' M 52 Oakville Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Osteryille MA 02655 3-28-14 required for every ' page. Cityrrown 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: System is in good working order with no sign of failure. B) System Conditionally Passes: El 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•3M 3 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 + 52 Oakville Ave Property Address . Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name a information is y y,•,z _ .•}, required for every Osterville MA 02655 3-28-14,- page. City/Town _ State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation-of sewage backup or break'out'or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will ` pass inspection if(with approval of Board of Health): r '' '• � broken pipe(s)'are replaced" ' ❑ "Y`•`❑ 'N, ❑ ND (Explain below): I , •, '❑ •obstruction is removed IT Y ❑1 N` ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑`Y ` ❑ N '❑ ND (Explain below): , „, ... �`5 a _r a~..3[Fi i :t ) L-y,{:I s•t+ . a+ J . V• k�. I ❑ 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: r ? ;,•� ; ❑ 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•3/13 a Trtle 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 'f 52 Oakville Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is Osterville MA 02655 3-28-14 required for 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**. 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 El ® due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less than 1/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form-Not for-Voluntary Assessments:,, x: 52 Oakville Ave r a t Property Address .- Bank Owned (Contact David Holt @.Today Real Estate 1-800-966-2448), Owner Owner's Name information is required for every Osterville i , 4 MA 02655 3-28-14 page. Cityfrown n. State Zip Code Date of Inspection B. Certification (cont.) s't 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. - =.t" ^❑ . .. �.®; o ,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. ❑ 1Z rAny 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- } ®a, 101000gpd. 1 , f The system fails: I have determined that one or more of the above failure ❑ "®' r 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 Eu w necessary.to correct the failure. i E) Large Systems: To be considered a large system the system must serve a facility with a y 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 ❑ '�.'❑ i. Area— IWPA) or a mapped Zone'11 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•3113 - z r Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 52 Oakville Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is , required for every Osterville MA 02655 3-28-14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes No ' f ❑ ® 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? Ell ® 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) ® ❑ Mas 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts $w„ . . •.� Title 5 Official Inspection Form . !m Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments. 52 Oakville Ave f Property Address F Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)!- Owner Owner's Name - information is Osterville required for every MA 02655 3-28-14 ' page. CitylTown } State Zip Code Date of Inspection D. System Information ti: Description: Number of current residents: - Does residence have a garbage,grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? �� , ,;� n ❑ Yes ® No r .! Seasonal use? :� �> . .� �� - ❑ Yes ® No Water meter readings, if available last 2 ears usage d :'-,i 9 ( y 9 (gp )) � • Detail: Sump pump?., - �. tA. ❑ Yes ® No I Last date of occupancy: 3-2014 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow„(based on 310 CMR 15.203): .} ., "r - Gallons per day(gpd) p: Basis of design flow(seats/persons/sq.ft.;etc.): .. Grease.trap present?. , ..trFF;. ° . :.¢ ^.t t a. r. ❑ Yes ❑ No Industrial waste holding tank present? , . ,,' .z, ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system?: ❑ Yes ❑ No Water meter readings, if available: ` t5ins-3113' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts A . . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 52 Oakville Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 3-28-14 page. Cityrrown 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: N/A 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: III ® 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): Pump chamber. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts y.._ . r -: _ a :1 R W Title 5 Official Inspection Fora x:h ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 52 Oakville Ave Property Address Bank.Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name _ information is Osterville i MA 02655 3-28;14 " required for every - +- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: 2010 Were sewage odors detected when arriving at the site? ,, t .❑ Yes ® No Building Sewer(locate on site plan): , a + , r^f•t Depth below grade: 10'6" �, i ' ' j'"feet Material of construction: ❑ cast iron ® 40 PVC '� ❑ other(ezplainj: Distance from 'private water supply well or suction line: feet. Comments(on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance? (attach a'copy of certificate):. ❑ Yes ❑ No Dimensions: - 1500 gal Sludge depth: , 12" t5ins-3/13 } Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 52 Oakville Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville - MA 02655 3-28-14 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 20" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and.outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Recommend pumping tank to remove solids and clean the Zabel filter at outlet. 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form .. , . Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments P •''r 52 Oakville Ave x w; Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) > , Owner Owner's Name information is �• required for every Osterville MA 02655 3-28-14 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 El fiberglass ❑ polyethylene ❑ other(explain): ° Dimensions: ,+� •• a -- Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No' Alarm level.' Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3/13• Title 5 Official Inspection Forth: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 52 Oakville Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 3-28-14' 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): - Good condition with water at wonting level and no sign of back-up from chambers. 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.): Pump and alarm were tested and found to be in good working order. * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Y • . a, ' } t. r r Title 5 Official Inspection Formk Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments.•r F+ ° M 52 Oakville Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) . Owner Owner's Name information is required for every Osterville MA 02655 3-28-14 page. Cityrrown _ State Zip Code Date of Inspection D. System Information (cont.) is . . , Type: .; +► r '. . . -� •i} - � � 4• .�_. . ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ •• leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ' ❑ overflow cesspool number: ❑ - innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach chambers were in good condition and empty at inspection with stain line at 3"off chamber bottom. 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 3113 .'. , . F 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 Forme-Not for Voluntary Assessments M 52 Oakville Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 3-28-14 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 f , Commonwealth of Massachusetts �P :-. F =J 1",", : Title 5 Official, Inspection Form, ., . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments-, f 52 Oakville Ave Property Address , r Bank Owned (Contact David Holt Today Real Estate 1-800-966-2448)' Owner Owner's Name information is required for every OStervllle ". � -; ,�,; MA 02655 3-28-14, , page. City/Town _ State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the.boxes below: ® hand-sketch in the area below ❑ drawing attached separately L c e a= - 77 0 6 - 5"3 a 0 {, r ! t.....4 1f r 11 . �' r .;1s�•1`.'{ +xr' :-i. t - z"• rp f .-r` . t5ins-3/13 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Oakville Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 3-28-14 page.e. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -'explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts - F Title 5 Official Inspection Form ' o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Oakville Ave Property Address Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) Owner Owner's Name information is required for every Osterville MA 02655 3-28-14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN 3iF BARNSTABY.0 sm ` A� s - �E1F'tT�C TANK(,J�&�AC.'l'CY ............. , i .S' III LcYirntc Y .� f PER:N.tlTD. TTl1.;. ,.., :_^ «.:.� :..wCC�1 9"C.II�SdT4 1�J4TS•... . ... ,: �. Se� iratload 1I �, cre,1v�en feet Mnxitnixinl sJjws�ecl'G�puladwat�r'X'rrbkta tlac i3crttr}rn o9' achtn t?sleility -�-w- Phlv s4oply well,wl'c3 L604 140 (Ar ILPy Foot G, all sstG nr�vithitt?!lq feat ak taagtx►�1t;fatc.e�i't}�) .. ---r—� ---�.�-� Eclat;<}f 1�Jet�aW pod.,�L.oAc9}.11g�40, �Yf:a�1y ivctAaaldS isf �w -� D D ° I Li A-/,- a5' 9-�- s3G • 90 ' v t TOWN OF BARNSTABLE &C CATION 5 2, 0"V LLB C10c SEWAGE# '2-0 I ® Z-�-5_ ILLAGE ASSESSOR'S MAP&PARCEL J' N®`7 INSTALLER'S NAME&PHONE NO. �ktvt> �DLL-L- SEPTIC TANK CAPACITY. I scb LEACHING FACILITY: (type) `C' S—b® (size) a'A �_h O 6-L. NO.OF BEDROOMS 3 OWNER �l ��(L LC. PERMIT DATE: 0 COMPLIANCE DATE: /0 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility --t:- 1 Z 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 an wetlands exist within A 300 feet of leachin facility) Feet FURNISHED BY E� - .� 6g so a-0 qq - a . 9-2- -� No. o Fee_ THE COMMONWEALTH OF'MASACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN'OF BARNSTABLE, MASSACHUSETTS Yes application for Nsposal 6pstrin (Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. i I� ® ®0-7 Owner's Name,Address,and Tel.No. 1Z t"4 _B LI AP_1 L L. Assessor's Map/Parcel SZ OAkv 1 Lk—1:5' Z oAr4yj os-rfi J i 1 Lg Installer's Name,A dress,fand Tel.No.�i Designer's Name,Address,and Tel. o. o Z MA"-170nl5 IIAIW i #44f4 6140 1 -50 5[ V�ra 960%01446 , /44 0 Type of Building: Dwelling No.of Bedrooms s Lot Size 8 11 '2—sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Shower feteria( ) Other Fixtures Design Flow(min.required) O gpd Design flow provided gpd Plan Date 1 - 5 -- )- C!) Number of sheets Revision Date Title PP__O T ��-}+ % i,�4 S��— Z)gzsi r yN Size of Septic Tank 1,64'y C Ab (LJ137TA Type of S.A.S. C h FaJ ! Description of Soil W' $� P.P% Te.3� Nature of Repairs or Alterations(Answer when applicable) 2��l p� Sy Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Co a and riot to place the system in operation until a Certificate of Compliance has been issued by this Boar f Health. Si Date Application Approved Date l Application Disapproved by Date for the following reasons Permit No. ` �✓!Q Date Issued ------=---------- - - i�;rl","`` i�'��-h•:;qy_...,,.+,,,y."^..s�`�^.'*►+yw+,..^hi"�C�'V'`�6.A;r.itn��+a*+wow"+.�+%tei:r.�a..,.f�..-_----.�.....� ,;f;,...,.�,,.....,,r;.,,,...._�.._, ...,...--•--- -s..-. ..,• .,.-..r .., -..._� K A No. C�7 16 —Cl✓7 b vA- y.. Fee pu , i. THE COMMONWEALTH OF UASSACHUSETTS Entered in comTpater: Yes PUBLIC HEALTH DIVISION -Y WN-OF BARNSTABLE, MASSACHUSETTS 2ppYication for his#oral Opstetn construction ter tnit -Application for a Permifto Construct( ) Repair( ) Upgrade(, Abandon( ) ❑Complete System Q Individual Components Location Address or Lot No. I/ ,�. OO-7 V,'v Owner's Name,Address,and Tel.No. f ? I v n 1Zl Gl-k -13 U Ra21 LL Assessor's Map/Parcel SZ p v i L.L� F vr::' S"z. O I Ve US"rcztl/ t& m4 Installer's Name,A dress,and Tel.No. Designer's Name,Address,and Tel.Igo. n bZ MA25ToNS !tl-5 14 D o' `�X I:¢c 5A1Jb0t /lit 02� Type of Building: " C Dwelling No.of Bedrooms Lot Size 2—sq,ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers,(�)aCafeteria( ) Other Fixtures o�� Design Flow(min.required) gpd Design flow provided • 3 f gpd Plan Date I - 5 CJ Number of sheets Revision Date Title T�ILO PQ�:,)--) S t'� GN Size of Septic Tank 05 V -0 a A it Csjo 5"T"A �_) Type of S.A.S. Description of Soil C.)- B:, �_o M J �( ,3� �- 1 O{�M'\y SA D I . Nature of Repairs or Alterations(Answer when applicable) ,�� L �N S , f\ s 5 , Date last inspected: J ) - )D " Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environment4Coed not to place the system in operation until a Certificate of Compliance has been issued by this Board'of Health. g'ned Date j � 1 Application Approved by, \ Date Application Disapproved by Date for the following reasons Permit No. 0 /Q Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by at _ �� C�A �()L�, •� C� S� 1FN ) L CGhas been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No... /. dated InstallerA Designer A�, �I Z E L #bedrooms �— Approved design flow A gpd The issuance of this permit+shall not be construed as a guarantee that the system will fun tic on as designed.- / Date Inspector t �j No. C?,f PD Feed THE COMMONWEALTH OF MASSACHUSETTS A* PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pste Construction permit Permission is hereby granted to Construct( ) Repair( 7 Upgrade( ) Abandon( ) ` System located at L ( E' `f �� � L F and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction Tust be completed within three years of the date of thi l permit. Date I 10 Approved,,by Town of Barnstable Regulatory Services •`t Thomas F. Geiler,Director BARNgrABM NUM Public Health Division 39. Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Date:3� � Sewage Permit# 2010 7!!� Assessor's Map/Parcel S / O0� Installer& Designer Certification Form Designer: C� � �•�' � � • Installer: ��'Yi'1 Lkz-L Address: ' gj' Address: `FE p; t y u -7t)-7— Y'6 On �� A a,� was issued a permit to install a (date) (installer) septic system at e— C AK-V t s-� &L,� ®s-rmih`bra ed on a design drawn by (address) dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. . Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if required) was inspected and the soils were found satisfactory. N Of Mks (Installer's Slgnatu HARRY y�N EARL LANTERY, JR. A p No.26575 p esi r s Signature) (Affix ONAI ere) � , PLEASE URN TO BARNS ABLE P C ALTH DIVI ION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED TH, BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION:. THANK YOU. gAoffice formsWesignercertification fotm.doc V Commonwealth of Massachusetts luCity/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal MassDEP has provided this form for use by on-site professionals and local Boards of Health. Other forms may be used, but the information must be substantially the same as provided here. Before using this form, check with your local Board of Health to determine the form they use. A. Facility Information M?a- Ra a 152,U Owner Name s 2 �aKv ytL1E A���r v 148- ao T Street Address Map/Lot# MA City State Zip Code B. Site Information 1. (Check one) ❑ New Construction ❑ Upgrade (Repair 2. Published Soil Survey Available? Yes ❑ No If yes: Year Published Publication Scale Soil Map Unit i Soil Name Soil Limitations 3. Surficial Geological Report Available? ❑ Yes No If yes: Year Published Publication Scale Map Unit Geologic Material Landform 4. Flood Rate Insurance Map Above the 500-year flood boundary? ❑ Yes No Within the 100-year flood boundary? E/Yes ❑ No Within the 500-year flood boundary? Yes ❑ No Within a velocity zone? t� ElYes VNo 5. Wetland Area.1juj C National Wetland Inventory Map '?_S 0��1 ��� ~ 'T_�Mil „A Map Unit Name Wetlands Conservancy Program Map Map Unit Name t5forml1.doc•rev.10/07 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 1 of 8 AV�NUE APPROXIMATE SCALE ZONE C 5000 500 FEET RATIONAL FLOOD INSURANCE PROGRAIi') FIRM FLOOD INSURANCE RATE MAP 0 ATE ROAD FLOOD INSURANCE NOT AVAILAE TOWN OF OR SUBSTANTIALLY IMPROVED NOVEMBER 16,1990IN DESIGNA7 BARNSTABLE, MASSACHUSETTS BARNSTABLE COUNTY PANEL 16 OF 25 ISEE MAP INDEX FOR PANELS NOT PRINTED) - 90 THIS MAP INCORPORATES APPROXIMATE BOUNDARIES OF COASTAL'SARAMP RESOURCES SYSTEM UNITS AN01OR- sjy OTHERWISE PROTECTED AREAS ESTABLISHED UNDER THE •-.��r "., 1 ` COASTALSARRIERIMPROYEMENTACTOF 1990(PL t0159) t may' COMMUNITY-PANEL NUMBER MAP REVISED: JULY 2,1992. •Yl �t a1_ �y ZONE C z K i xr� r i Federal Emergency Management Agency This is an official copy of a portion of the above referenced flood map. It was extracted using F-M IT On-Line. This map does not reflect changes or amendments which may have been made subsequent to the date on the title block. For the latest product information about National Flood Insurance r _ ❑ '•s �"-`' Program flood maps check the FEMA Flood Map Store at www.msc.fema.gov Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal B. Site Information (Continued) 6. Current Water Resource Conditions(USGS): Month/Year Range: ❑ Above Normal 'Normal ❑ Below Normal 7. Other references reviewed: C. On-Site Review (minimum of two holes required at every proposed primary and reserved disposal area) � iJ �z�-�o o c Deep Observation Hole Number: l �1 � ;Date Time Weather 1. Location Ground Elevation at Surface of Hole: Location (identify on plan): 2. Land Use 1ZL—�1 Die 1)i 41. PZ 1 C$ (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) Vegetation Landform ) Position on Landscape(attach sheet) i 3. Distances from: Open Water Body feetb ® Drainage Way lt)feDo Possible Wet Area jjR Property Line feet t� Drinking Water Well fee' Other feet 4. Parent Material: o TW S } Unsuitable Materials Present: VYes ❑ No If Yes: ❑ Disturbed Soil ❑ Fill MaterialImpervious Layer(,) ❑ Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed: ❑ Yes [(No If yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: ! 1 .? 0 > .8 g inches elevation t5forml 1.doc•rev.10/07 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal -Page 2 of 8 <Cl\ Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Continued) * ) Deep Observation Hole Number: Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Consistence Other Layer Moist(Munsell) (USDA) Cobbles& Structure (Moist) Depth Color Percent Gravel Stones �= 3A- !3 1 0�► S > > sob 44 3+ Y s s -7 a"I Y C -z 2 3 y ` 3 ' Sid r� 2 10 1 n ast� Additional Notes: 11 -<,5PAjw_/jN , t5forml1.doc•rev.10/07 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8 �L\ Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Continued) 2 Il' ZS- +7� 1 0_0o CLk1 CooI. Deep Observation Hole Number. Date Time Weather 1. Location Ground Elevation at Surface of Hole: Location (identify on plan): 2. Land Use L to r (e.g.,woodland,agricultural field,vacant lot,etc.) Surface Stones Slope(%) Gg o . y ��7 ]?,A)4 Vegetation I Landform Position on Landscape(attach sheet) 3. Distances from: Open Water Body Drainage Way >feet Possible Wet Area > j Property Line -q-O/ Drinking Water Well 'V�J Other feet feet feet 4. Parent Material: � c Unsuitable Materials Present: /Yes ❑ No If Yes: ❑ Disturbed Soil ❑ Fill Material ld Impervious Layers) ❑ Weathered/Fractured Rock ❑ Bedrock 5. Groundwater Observed: ❑ Yes /No �f If yes: Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater. > I (dd , 65 inches elevation t5form1l.doc•rev.10/07 Form 11—Soil Suitability Assessment for On-Site •Sewage Disposal Page 4 of 8 P 9 Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (Continued) 2 Deep Observation Hole Number: Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Layer Moist Munsell (USDA) Structure .Consistence Other Y ( ) ) Cobbles 8 (Moist) Depth Color Percent ravel Stones O ,�, t o O• 3�,�, 1 > L o AM --:*) 3g_7Z CI 1a13ks/z , S U> > L 72 .1� 4 CZ 2.5 X ' A t Additional Notes: t5forml 1.doc•rev.10/07 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 5 of 8 Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal D. Determination of High Groundwater Elevation 1. Method Used: ®� - ❑ Depth observed standing water In observation hole A.inches -� inches ❑ Depth weeping from side of observation hole A. o r�� B. inches l ) inches ❑ Depth to soil redoximorphic features (mottles) A. � /v B. N inches f 1� iinnches ❑ inches inches 2. JV Index Well Number Reading Date Index Well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a. Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil abs rption system? [ Yes ❑ No b. If yes, at what depth was it observed? Upper boundary: inches Lower boundary: inches t5forml 1.doc•rev.10/07 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 6 of 8 Commonwealth of Massachusetts 4 City/Town of A Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal F. Certification I certify that I am currently approved by the Department of Environmental Protection pursuant to 310 CMR 15.017 to conduct soil evaluations and that the above analysis has been performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. [further certify that the results of my soil evaluation, as indicated in the attached Soil Evaluation Form, are accurate and in accordance with 310 CMR 15.100 through 15.107. Signat e Soil or o 2Y Dat G T;ped or Printed Name of Soil Evaluator/License# - c, LANTFRY• a valuator Exam 26 Name of Board of Health Witness 1ST Hea h �''SIONAt- Note: In accordance with 310 CMR 15.018(2)this form must be submitted to the approving authority within 60 days of the date of field testing, and to the designer and the property owner with Percolation Test Form 12. t5forml 1.doc•rev. 10/07 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 7 of 8 e Commonwealth of Massachusetts City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal Field Diagrams Use this sheet for field diagrams: t5form11.doc•rev.10/07 Form 11—Soil Suitability Assessment for On-Site Sewage Disposal •Page 8 of 8 TOWN OF BARNSTABLE ✓� 1110C,�TION - C� �+/Its .d c/ SEWAGE A V71 .LEkGE ASSESSOR'S MAP & LOT&J ®/ INSTALLER'S NAME&PHONE NO. SEP'nC TANK CAPACITY i LEACHING FACILrrY: (type) L- C- (size) 1�- NO.OF BEDROOMS a BUILDER OR OWNER ,2 /L i f PERMITDATE: % COMPLIANCE DATE: rd 3� Cl Separation Distance Between the: Maximum Adjusted Groundwater Table d Bottom of Leaching Facility Feet Private Water Supply Well and Leac-'ng Facility (If any wells exist on site or within 200 feet of leadthing facility) Feet Edge of Wetland and Leachin acility(If any wetlands exist . within 300 feet.of leachi g facility) Feet Furnished by LI� 1 J ci . 007 �13 � Q $50 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes 0[pprication for Migozal *pztem Con6truction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 52 Oakville Ave . , Osterville, MA Richard. Burrill Asssessor's,�Map/,Parcdk7yel I Ia •r sL' eK O lstr Tel �'e pt i c Service Designer's Name,Address and Tel.No. uPV 0 Box 1089, Centerville , MA Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S and. Nature of Repairs or Alterations(Answer when applicable) new Title-5 septic system tank, D-box and. 2 leach chambers Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental C de and not to place the system in operation until a Certifi- cate of Compliance has been issu d by thi_sj1oarj4,6f JIealth. h� Signed Date Application Approved by Date y1 Application Disapproved for Ke fol owing reasons Permit No. T90— Date Issued g A 4_ No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASS4CHUSETTS ` 01ppUration for �Digpogal *pgtem Congtructi.on Permit Application for a Permit to Construct( )Repair(K )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 52 Oakville Ave. , Osterville, MA Richard. Burrill Assessor's Map/Parcel taller's ame d ss and Tel. Designer's Name,Address and Tel.No. m. o 1 S N§*eptic Service P 0 Box 1089, Centerville, MA Type of Building: Dwelling No.of Bedrooms 9 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) N1 Other Fixtures t 'Design Flow gallons per day. Calculated daily flow gallons. "'Plan Date Number of sheets Revision Date Title " Size of.Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) new Title-5 septic system tank, D-box and. 2 leach chamb#rs Date last inspected: Agreement: M �' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi cate of Compliance has been issue by this 4ar;4f Ijealth. Signed o l Date Application Approved by Date��e_ 2/ Application Disapproved for Me fol owing reasons Permit No. / - 2Z Date Issued THE COMMONWEALTH OF MASSACHUSETTS Burrill BARNSTABLE, MASSACHUSETTS (tertificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( X )Upgraded( ) Abandoned( )by Wm. E., Robinson Septic Service at 52 Oakville Ave . , Osterville, NIA has been constructed in accordance with the provisions of_Title 5 apd the for Disposal System Construction Permit No.- ��dated Installer Wm. E . 'Rob ins on S f. Designer Desi g �� A C' The issuance of this e ' �t shall nNq e construed as a guarantee that the sy tae will functio�nr as d�signe Date ! Inspector l.''Iv, �_�r`' �' t�• , �Y� ll�' i --------------------------------------- No. — Fee $5 0 THE COMMONWEALTH OF MASSACHUSETTS Burrill PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 'Wi5pogal *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) System located at 52 Oakville Ave . , Osterville, MA and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: - E`�J _ �/ Approved by ,� 14 ✓L 1/6199 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) r y � I, William E . Robinson,S,'hereby certify that the application for disposal works construction permit signed by me dated J�oZ�_ , concerning the property located at 52 Oakville Ave . , Osterville , MA meets all of the following criteria: • Tfi failed system is connected to a residential dwelling only. There are no commercial or business use associated with the dwelling. • Th soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • Ire a no wetlands within 100 feet of the ro sed s tic stem e are proposed septic sy • ere are no private wells within 150 feet of the proposed septic system • ere is no increase in flow and/or change in use proposed • ere are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +the MAX.High G.W. Adjustment. = ' I J l� DIFFERENCE BETWEEN A and B Z SIGNED : � DATE: [Sketch proposed plan of system on back]. q:health folder:cert r -.� ., �G � l� _ � ti /� � ., �,�� � � J TOWN OF BARNSTABLE LOCATION S - �ll 1 t .d c/ SEWAGE # VILLAGE 1 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. Z— 7 '7 4 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) , -—.�_ — 1- �- (size) 6, fir ` NO.OF BEDROOMS BUILDER OR OWNER )'S'b /Z A— r 1 PERMITDATE: �'g �7 COMPLIANCE DATE: 16 3 7 Separation Distance Between the: Maximum Adjusted Groundwater Table a�d 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 Leachin '1~acility(If any wetlands exist within 300 feet of leachidg facility) Feet Furnished by o• - -1J TEST PIT f- PERC. TEST ` EXISTING 52jOakville'I"V 5 EXISTING L.C. 2 2G'x 1 P 2 el. 88.0 # 1 GRADE # 2 Osterville, Md TO BE ABANDONED 99 0- -102:0 ` 98.3- LOAM 101 .3 LOAMY SAND ° PERC RATE < 2 MIN/IN. 95.7 - OZ ° 1000, No. 2-\ s�c'F _ 1 vi 66 ,00 MEDIUM SAND __ ". `� 2 ° \ -I' No. �\15 �No. I 93.0- 9G.0 \ \ //'00 0 DE51GN •PROPO5ED P MP CHMBR. EXIST. N \� A `° S.T. SINGLE FAMILY DWELLING W/3 BEDROOMS OAS ,�--�_° MED - COARSE SAND NO GARBAGE DISPOSAL DAILY FLOW= I 10 x 3= 330 G.P.D. \/ SEPTIC TANK(VOL. REQ'D) N� Nc. 52 i STY. 330 G.P.D. x 2 = GGO GALS WD. FPR. 1500 GAL.TANK-O.K. (EXISTING) \ 89.0 NO WATER NO WATER 92.0 / - - LEACHING AREA(S.A.S.) /� Q� USE 2Q 5'x 8'x 2' P.C. CONC. L.C. 4' STONE A�7I N I 48-007 EFFECTIVE DEPTH = 2.0 2 X[48+ 2G] x 0.74 = 1 10 r 24 x 13 x 0.74 = 231 (28, 1 12-�-SF - RECORD) TESTED : I I/25/09 TOTAL CAPACITY = 341 GAL5. fool WITNES: DON DESMARAIS, R.S. OAKVILLE AVENUE NOTES: BENCHMARK: MAG NAIL SET. O ELEV. 100.00 (ASSUMED). 1• DISPOSAL SYSTEM TO BE CON5TRUCTED IN STRICT ACCORDANCE WITH �Q COMMONWEALTH OF MA55ACHU5E)T5 ENVIRONMENTAL CODE TITLE V. 2. LOCUS IS SHOWN A5 APN 143-007 ON THE TOWN OF BARNSTABLE ASSESSORS' MAPS. \ 3. CONTRACTOR TO CALL DIG-SAFE 72 HOUR5 PRIOR TO BEGINNING CONSTRUCTION \ _ AND/OR EXCAVATION. 4. CONTRACTOR-TO-CHECK INVERT OF EXISTING TANK. 5. PUMP SEPTIC TANK, CHECK T'5 AND INSTALL GAS BAFFLE; ABANDON LEACH FIELD. EL. 88.0 GRAPHIC 5CA1 E G. THI5 PLAN 15-NOT RECORDABLE, NOR DOE5 IT DEPICT ANACCURATE PROPERTY SURVEY, AND IS THEREFORE NOT TO BE°USED FOR CONSTRUCTION OF ANY KIND, OTHER THAN THE ELEMENTS 40 0 20 40 80 OF THE SEPTIC SYSTEM, AS SHOWN. j 7. THE SITE BENCHMARK 15 DASED ON AN A55UMED ELEVATION A5 5HOWN. LEGEND 8. LOCU5 15 SERVED BY TO�NN WATER. ( IN FEET ) 9. U5E 2 @ 8' x 5' x 2' P.C. CONE. LEACH SCHAMBER5, WITH_4' OF 4' TO I2' DOUBLE WASHED I = 40' STONE ALL AROUND WITH 2" LAYER OF WASHED PEASTONE ON TOP. 24 �- '� PROPOSED CONTOUR 10. PLACE 1 ,000 GAL. PUMP CHAMBER ABUTTING THE EX15TING 1 ,500 GAL. 5.T. 1 1 . USE 2 H.P. PUMP W/PUMPING HEAD OF 12. 0 12. PUMP OFF: 3" FROM'',BOTTOM. 51TE PLAN �� ��� EXISTING CONTOUR PUMP ON: G" FROM TOP ALARM ON: 9" FROM BOTTOM. (SEPARATE CIRCUIT) DRIVEWAY 13. PUMP TO DISTRIBUTION BOX, W/7" TO REDUCE FLOW, GRAVITY FEED TO LEACH CHAMBERS. U5E 5CHEDULE 40 PVC - 4" PIPE FOR GRAVITY� 2" 5CH€DULE 80 PVC FOR PRESSURE LINE 111311FIRM ZONE ROM PUMP. I CE ZABEL FILTER IN OUTLET'T' OF SEPTIC TANK. FIRST FLOOR EL. a VENT FILTER MIN P OF WALL REMOVE IMPERVIOUS . MATERIAL 5'AROUND SYSTEM TO EL. 9G.2 EXISTING GR. EL G"MIN./3'MAX.COVER ACCESS PORTS FIN. GR, EL. 2%SLOPE W/IN 3"OF GRADE J C� ESSW/IN �� �� /�� \� �� \/ / \�/\� �/\ ��• MI COVER /\ /\/�/\/. /�\/��. / ryjq .� G"OF GR. 9"MIN. COVER ti�tt �� SF ,, 2 PEASTONE EX15T. 1 500 VO O TEST I�({RRY32"DIA. " �daooEARL�/ GAL TANK 1000.6AL. R LEVEL j EL. 90.0 (H-20) PUMP CHAMBER PUMP 2'LEVEL _ 3�� L Y, JR. �: HEALTH AGENT APPROVAL DATE (H-20) D-BOX EL. 97.9 �A p N .265 FIELD EL 89.7 - (EMERGENCY o8^$a°�c�B°8 b ° ' �°$ �cFS 1 STe P.C.CONC. �� $ 4 `"� CHECK 5TRGE=G70 G) G"MIN. t, ,o EL 95.9 a8" Y8 JCJ L EL. 98.4 EL 98.2 ° o 08 0$ .°- DEPTH OF LIQUID -4' ` G"CRUSHED STONE OR COMPACTE9 10'MIN INLET TEE DEPTH - 10"MIN. 2"MIN. PROPOSED SEPTIC SYSYTEM DESIGN OUTLET TEE DEPTH - 14"MIN. 5'MIN- 20 MIN. I 52 OAKVILLE AVENUE H2 O BELOW BARNSTABLE (05TERVILLE) MA EL. 89.0 PREPARED FOR: RICHARD 13URRILL DE51GN BY: SURVEY BY: DATE: SCALE: JOB No. PROFILE OF DISPOSAL SYSTEM ADVANCED TECHNICAL5OLUTION5 r.j. hood*5on, Inc. 05JAN10 I" = 40 09209 Z�P Q ✓) P.O.BOX 99 18 ROUTE GA ( DRAWING NOT TO SCALE ) EAST SANDWICH,MA02537 SANDWICH,MA025G3 DhRAWN: tCHECKED CHECKED(Survey) 774.313.9547 508.833.7100