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0105 OLD EAST OSTERVILLE ROAD - Health
105 Old -East Osterv.ille �oa Osterville F/R A 145 020 l I Commonwealth of Massachusetts GINAL YOFJ - Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Osterville MA 02655 May 4 2011 required for every y , 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 forms A. General Information on the computer, 34b-&S5 / use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector r ,, z . y David B. Mason Q r� Company Name y 4 Glacier path Company Address East Sandwich MA 02537 Citylrown State Zip Code 508-833-2177 S1287 Telephone Number License Number ,. M.- 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 s May 4, 2011 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a sharedjsystem 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 conditiions 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. ( I t5ins•09/08 Title 5 Official Inspection Form:Subsurf4Sewaposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,a 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Y Osterville MA 02655 May 4 2011 required for every , page. City1rown State Zip Code Date of Inspection B. Certification (cone.) 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: Inspection of system represents the condition of the system for only May 4, 2011 at 1 PM. There is no quarentee of the continued operation of the system beyond the inspection date. 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•09/08 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 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owners Name information is Osterville MA 02655 May 4, 2011 required for every y page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Y Osterville MA 02655 May 4 2011 required for every , page. Cityrrown 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 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 Y day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is y Osterville MA 02655 May 4 2011 required for every , page. Cityrrown 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 iD 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•09/08 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 GSM , 105 Old East Osterville Road, Osterville - Property Address Kellie Lucy Owner Owners Name information is Osterville MA 02655 May 4 2011 required for every y page. Citylrown 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? ❑ ❑ 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / ;M 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owners Name information is Osterville MA 02655 May 4, 2011 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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? El Yes ® No Water meter readings, if available (last 2 years usage(gpd)): yes Detail: 2009; 36,000 gallons and 2010 35,000 gallons. Sump pump? ❑ Yes ® No Last date of occupancy: current 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Osterville MA 02655 May 4 2011 required for every Y , 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M s 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is y Osterville MA 02655 May 4 2011. required for 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: December 2, 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Not Applicable feet Comments (on condition of joints, venting, evidence of leakage, etc.): Appears in working order Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gallon tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth- t5ins•09/08 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 ,..°y 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Y Osterville MA 02655 May 4 2011 required for 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 38" Scum thickness 2" 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 8., How were dimensions determined? Scour stick 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 in good operating condition. No issues observed. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Osterville MA 02655 May 4 2011 required for every , page. Citylrown 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•09/08 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 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Osterville MA 02655 May 4, 2011 required for every Y page. Cityrrown 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 Level with outlet inverts Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No evidence of solids carryover. Dbox is approx. 12 inches below grade. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Osterville MA 02655 May 4, 2011 required for every Y page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): 2-500 gallons chambers with 4 feet of stone around. No ponding in units. No damp soil. No excessive vegatative growth. 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•09/08 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 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Osterville MA 02655 May 4, 2011 required for every y page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is y Osterville MA 02655 May 4 2011 required for every , page. Cityrrown 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 t5ins•09108 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 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Osterville MA 02655 May 4, 20.11 required for every y page. Cityfrown 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: 20 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: for area Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Engineered plan on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: - You must describe how you established the high ground water elevation: Used engineered plan on file based on test hole data and Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I Commonwealth of Massachusetts - Title 5 Official Inspection Form a e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c M 105 Old East Osterville Road, Osterville Property Address P Y Kellie Lucy Owner Owner's Name information is Osteryille MA 02655 May 4 2011 required for every , page. CitylTown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17.of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form WGINA Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information equ red for is //�� y�I Q r V I I It MA 02601 May 4, 2011 required for 1G..:11 every page. City/Town v 0*19 = I N,5 - 000 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 computer,use 1. Inspector: only the tab key to move your David B. Mason cursor-do not Name of Inspector use the return key. David B. Mason Company Name VQ 4 Glacier path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-833-2177 S1287 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the tv information reported below is true, accurate and complete as of the time of the inspection.The inspection UJI v, 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: M:_ M ®` Passes ❑ Conditionally Passes ❑ Fails C> ❑'Needs Further Evaluation by the Local Approving Authority �.. a f: t P May 4, 2011 1 pector's ature 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage sposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Centerville MA 02601 May 4, 2011 required for Y every page. City[rown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspection of system represents the condition of the system for only May 4, 2011 at 1 PM. There is no quarentee of the continued operation of the system beyond the inspection date. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments M 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Centerville MA 02601 May required for Y 4, 2011 every page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °� ,•'' 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Centerville MA 02601 May 4, 2011 required for y every page. Cityrrown 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 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 'h day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is y required for Centerville MA 02601 May 4, 2011 every page. Cityrrown 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 CM 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•09/08 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 ,. 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Centerville MA 02601 May 4, 2011 required for Y every 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 ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is required for Centerville MA 02601 May 4, 2011 every page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents:. 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): yes Detail: 2009; 36,000 gallons and 20110 35,000 gallons. Sump pump? ❑ Yes ® No Last date of occupancy: current 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i M 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is y required for Centerville MA 02601 May 4, 2011 every page. City/Town State Zip Code bate 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•09/08 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 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is required for Centerville MA 02601 May 4, 2011 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: December 2, 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Not Applicable feet Comments(on condition of joints, venting, evidence of leakage, etc.): Appears in working order Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1000 gallon tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-09/08 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 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is required for Centerville MA 02601 May 4, 2011 every page. Cityrro`n n 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 38 2" Scum thickness 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 8" How were dimensions determined? Scour stick 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 in good operating condition. No issues observed. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Centerville MA 02601 May 4, 2011 required for 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is required for Centerville MA 02601 May 4, 2011 every page. Cityrrown 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 Level with outlet inverts Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No evidence of solids carryover. Dbox is approx. 12 inches below grade. i 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•09/08 Title 5 Offidal 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 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is required for Centerville MA 02601 May 4, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): 2-500 gallons chambers with 4 feet of stone around. No ponding in units. No damp soil. No excessive vegatative growth. 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•09/08 Tice 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 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is required for Centerville MA 02601 May 4, 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: I Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Fora s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is y required for Centerville MA 02601 May 4, 2011 every page. Cityrrown 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 t5ins-09/08 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 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Centerville MA 02601 May 4, 2011 required for Y every page. 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: 20 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: for area Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Engineered plan on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Used engineered plan on file based on test hole data and Town of Barnstable groundwater contour map. Before filing this Inspection Report,,please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Old East Osterville Road, Osterville Property Address Kellie Lucy Owner Owner's Name information is Centerville MA 02601 May 4, 2011 required for Y 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f Assessing As-Built Cards Page 1 of 1 TOWN OFBAR,,NST�ABLE G LOCATION %b O !i�'O 5% U?--1 SEWAGE#- /3 2 Al VII.LAGE_ O�� ASSESSOR'S MAP&LOT 4ko WSTALLER'S NAME&PHONE NO. n 7 7 7 C y�Cj q G ev SEPTIC TANK CAPA= �� LEACHING FACn=: (type)Z' ���1`t 1. / C (size)_ 9 NO.OF BEDROOMS— BUILDER OR OWNER 0n ' PERMrrDATE: 2 -0 -- COMPLIANCE DATE: �f�—h2_ separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of g Facility Feet Private Water Supply Well and Leaching Facility (If weUs exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any we ds exist within 300 feet of leaching facility) Feet Furnished by 0 t t( XgC,, , ,( ED http://www.town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=145020&seq=1 5/4/2011 TOWN OF BARNSTABLE I,9�7A-r1ON o3- 0AI Ef 57- 057- R b SEWAGE # VILLAGE S T ASSESSOR'S MAP& LOT NAME&PHONE NO. A SEPTIC TANK CAPACITY S��T` l ASP-rc//oN LEACHING FACIL=: (type) (size) NO. OF BEDROOMS EB.UILDEWO OWNE C G /CA/ PERMTIDATE: DATE: 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 "< ,-,.�� �� ��a� ;,; 1'EAR `��c�fr �� �� y�� o < <,, 3�-� . . �° i TOWN OF BARNSTABLE ® G LOCATION /6 S" 441 4 kO S / SEWAGE # 0 VILLAGE (35 4 e : oll ASSESSOR'S MAP & LOT -0d0 INSTALLER'S NAME&PHONE NO. /('C SEPTIC TANK CAPACITY LEACHING FACT LTTY: (type) �'S'� `t L L (size) NO.OF BEDROOMS BUILDER OR OWNER S 'tl PERMITDATE: 6 2 COMPLIANCE DATE: 12--6 2 o�— Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Le hmg Facility Feet Private Water Supply Well and Leaching Facility ells exist(If on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any we ds exist within 300 feet of leaching facility) Feet Furnished by ` S vi9 a No. 2002 FeA 5 0.0 0 4 ITHE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zippfication for Migpooar bpotem Cong;truction Vermtt Application for a Permit to Construct( )Repair(xx)Upgrade( )Abandon( ) O Complete System EitIndividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 105 Old East Ost. R . Assessor'sMap/Parcel Osterville Elaine Bower Same 145-020 �Sigter'SIa 1 Installer's Aaf s oUpris'on Septic Servicedamn f TelOovhnson P.O. Box 1089 804 Main St. , Suite B Ty,p-e-of Building: Dwelling No.of Bedrooms J fit- r,&Lot Size sq.ft. Garbage Grinder( ) Other Type of Building res i entiaClNo.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) 1 u0L) Type of S.A.S. A 00 4-AF Description of Soil Nature of Repairs or Alterations(Answer when applicable) we will install a new Title-5 leach system to the plans of Dan Johnson #J-817 dated 11 /7/02. 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 th Onvironmental.Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thipto of Health. ff Signed �� Date Application Approved by S Date Application Disapproved for the ollowing reasons Permit No. )Uo 1—S�y Date Issued 1/— U—v a 4, . ,p No. . UO2-SS a ;�.1' Fee$5 0.0 0 Y • °`"' THF..., OMMONWEALTH OF MASSACHUSETTS Entered in computer: ' _ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS I 2pplication for loigpogaf bpgtem Congtruction Permit Application for a Permit to Construct( )Repair(Xx)Upgrade( )Abandon( ) O Complete System ..EkIndividual Components Location Address or Lot No. 10 5 Old East O S t. Rd Owner's Name,Address and Tel.No. r ' Assessor'sMag/ arcel Ostervillh Elaine Bower 14 -020 Same Installer's,IaTame,AddressxobinsOn Septic 'Service signer's' nWVdrgsVTel Nohnson � m. IJ. U 1lel. ttS3 ��11 T P.O. Box 1089 804 Main St. , Suite B Centerville, P V A► MA n26SS Type of Building: Dwelling No.of Bedrooms d�i e't"i .�f�Lot Size sq.ft. Garbage Grinder( ) Other Type of Building resi ent�xo.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank PlXl)� 100d Type of S.A.S. 2-�UU 44I1 " CPv�/�cr r ' - >7 ', Description of Soil r / Nature of Repairs or Alterations(Answer when applicable) we will 'i n s t a l laa new Title-5 leach system totthe plans of Dan Johnson #J-817 dated 11 7/02. A Date last inspected: Agreement: . The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of they'nvironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by o d.of Health. Signed Date /gyp Application Approved by 4-,- �.S Date / 20- u;2 Application Disapproved for the following reasons Permit No. . o '3$�l Date Issued /l-a U l THE COMMONWEALTH OF MASSACHUSETTS Bower BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( xx)Upgraded( ) Abandoned( )by Wm. E. Robinson Septic Service at 105 Old East Osterville,Rd. , Osterville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. a ode-56 V dated 1/-.,) u-o�2 Installer Wm. 8. Robinson Sr. Designer- , Daniel�,.B.. Johnson The issuance of this permit shall not be construed as a guarantee that the Isystem will function as designed. Date 11-o a 0 _ r Inspector �, A� _ _ Q P i Y VV`.` No. a 012- _-_q Fee$50.00 Bower , THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migpogal *pgtem Con!6truction Permit Permission is hereby granted to Construct( )Repair(xx)Upgrade( )Abandon( ) System located at 105 Old East Osterville Rd. , Osterville 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 rmit. Date: I I-:�U-o Approved by - 52S/CI1 NOTICE: This Form Is To Be Used'For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, dux Q. J °`V'_"u 2`1 hereby certify that the engineered plan signed by me dated 1t ?/0A concerning the property located at /of C1 D E�Jr o_rMti a r U— ,t.o os z w�cc - � meets all of the - - following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation"race is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase inflow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Fhmptor method when applicable]' Please complete the following:, A) Top of Ground Surface Tlevation (using GIS information) 3 o 3 B) G.W. Elevation /S. +adjustment for high G.W. '"h DUTEItENCE BETWEEN A and B 7 SIGNED : DATE: ) o � NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder.percr-=p { TOWN OF BARNSTABLE LOCATION /6 S" 0/6/ Ce` Sf G� % (F��G/ SEWAGE #'1-:L VELLAGE_ e �n���, ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /� G , ✓a.,s �v 7 7 �7 SEPTIC TANK'CAPACITY �d d LEACHING FACILITY: (type) 94 �. (size) NO.OF BEDROOMS e BUILDER OR OWNERS PERMIT DATE; COMPLIANCE DATE: Z �o�— Separation Distance Between the: . Maximum Adjusted Groundwater.Table to the BottoYds hing Facility Feet Private Water Supply Well and Leaching Facility ells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any west within 300 feet of leaching facility) Feet l Furnished by 06 i 1_ "1' f FIVED3 2002 COMMONWEALTH OF MASSACHUSETTSARNSTABLE DEPT. EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS + d DEPARTMENT OF ENVIRONMENTAL PROTECTION oe�M syav 350 MAIN STREET WEST YARMOUTH,MA ra 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP 145 PAR 020 FAILED INSPECTION Property Address: 105 OLD EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 Owner's Name: BOWER,ELAINE Owner's Address: 105 OLD EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 Date of Inspection OCTOBER 28,2002 Name of Inspector:(please print) JAMES D.SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yannouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that 1 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 Needs Further Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: _ Date: .0000 ' aiL 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 tot he buyer,if applicable,and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 1 f Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 105 OLD EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 Owner: BOWER,ELAINE Date of Inspection: OCTOBER 28,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: N/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: B. System Conditionally Passes: N/A _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. _ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with 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. ND explain: 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 obstruction is removed distribution box is.leveled or replaced ND explain: 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 obstruction is removed . ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 105 OLD EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 Owner: BOWER, ELAINE Date of Inspection: OCTOBER 28,2002 C. Further Evaluation is Required by the Board of Health: N/A 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 salt marsh 2. System will fail unless the Board of Health and Public Water Y ( e 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 105 OLD EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 Owner: BOWER,ELAINE Date of Inspection: OCTOBER 28,2002 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 pit is less than 6"below invert or available volume is less than %2 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) YES (Yes/No)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: N/A To be considered a large system the system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. 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) 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 is 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. Title 5 Inspection Form 6/15/2000 4 f Page 5 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 105 OLD EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 Owner: BOWER,ELAINE Date of Inspection: OCTOBER 28,2002 Check if the following have been done. You must indicate"yes"ot�"no"as to each of the following Yes No ✓ Pumping infonnation 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 nonnal 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? I ✓ 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 infonnation on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes No ✓ Existing infonnation. For example,a plan at the Board of Health. ✓ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CM 15.302(3)(b)] Title 5 Inspection Form 6/15/2000 5 f Page 6.of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 105 OLD EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 Owner: BOWER,ELAINE Date of Inspection: OCTOBER 28,2002 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): N/A Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CM 15.203): Basis of design flow(seatsipersons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N!A Was system pumped as part of the inspection(yes or no): YES If yes,volume pumped: 2,500 gallons—How was quantity pumped detennined? Reason for pumping: SYSTEM FULL-TANK AND PIT TYPE OF SYSTEM J 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) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: N/A Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 105 OLD EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 Owner: BOWER,ELAINE Date of Inspection: OCTOBER 28,2002 BUILDING SEWER(locate on site plan): J Depth below grade: 12" Materials of construction: Cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): J Depth below grade: 16" Material of construction: ./ concrete metal fiberglass polyethylene other(explain) If tank is metal list age: Is age confinned by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 2" 4i Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: ASBUILT AND 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.): MAIN TANK AT WORKING LEVEL. INLET TEE,OUTLET BAFFLE. GREASE TRAP(located on site plan) N/A Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): i I Title 5 Inspection Form 6/15!2000 7 Page 8 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 105 OLD EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 Owner: BOWER,ELAINE Date of Inspection: OCTOBER 28,2002 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(]ocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: OVER 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.,): DISTRIBUTION BOX IS 16"X16",24"BELOW GRADE.ONE LINE IN,ONE LINE OUT.BOX IS NO GOOD. NEEDS TO BE REPLACED. PUMP CHAMBER: N/A (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.): Title 5 Inspection Form 6/15/2000 8 r Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 105 OLD EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 Owner: BOWER,ELAINE Date of Inspection: OCTOBER 28,2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ./ leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT AND COVER 3 ''/z' BELOW GRADE.PIT IS FULL TO COVER. LEACHING IS FAILED. i CESSPOOLS: N/A (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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.): PRIVY: N/A (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.) I , Title 5 Inspection Form 6/15/2000 9 I Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 105 OLD EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 Owner: BOWER,ELAINE Date of Inspection: OCTOBER 28,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells w thin 100 feet. Locate where public water supply enters the building. Z>LL K �S �c Title 5 Inspection Form 6/15/2000 1 P 0 f Page I I of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 105 OLD EAST OSTERVILLE ROAD OSTERVILLE,MA 02655 Owner: BOWER, ELAINE Date of Inspection: OCTOBER 28,2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 30+ feet Please indicate(check)all methods used to detennine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observation 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: G.I.S. 9 P, 7- I Title 5 Inspection Fonn 6/15/2000 11 r i.' 0of /� 4 0 C A T ION �!� % sf' eti��/k36W A G E PERMIT NO. VILLAGE INSTALLER'S NAME i ADDRESS . 9 e UILDE R OR OWNER C�b� 1- S®lbws c��s� DATE PERMIT ISSUED __ DAT E COMPLIANCE ISSUED Zs_ d� i 9 J C;�7 31 � S�o No.T...3............... Fps............................_ THE COMMONWEALTH OF MASSACHUSETTS BOAR® F HEALTH l ®sue d, .............oF........1.. 1_41 „ ,_.ss -�- D v�' lipliratilan for UispwiFal Works Tonatrurtinra Vamit �a Application is hereby made for a Permit to Construct ( �or Repair ( ) an Individual Sewage Disposal System at: , ...�. _ . .._... J� �: r.VI-I�----------------------- Location- ress ......................................... or Lot No. Owner Address a /71-/- Q ?,11� ;-----•-----------------•--•--•---•-•----------•- ------•-••-------------.-.---------.---------•-------- Installer Address A Type of Building Size Lot..�.s... . Sq. feet U Dwelling—No. of Bedrooms..............3...:_ ._...Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons.................... a YP g ---------------------------- P •_------ Showers ( ) — Cafeteria ( ) Other fixtures - -----------------•--------•---:-....-•--.. W Design Flow.......... ��----_------.._-_-gallons per person per y. Total daily flow...3.. ...0.......................gallons. WSeptic Tank—Liquid capacityl�gallons Len h._s.. Width................ Diameter-___--__--_._ - Depth_....__......... P r x Disposal Trench—No._._......•._....... Width.j------)ef_--.-- Total Length .� Total leaching area....................sq. ft. Seepage Pit No...... ............ Diameter..ff__!�_...__ Depth below inlet...dz�......___.._... Total leaching area,9q. ft. Z Other Distribution box ( ) Dosing ) // ~" Percolation Test Results Performed b �!/. .......................... Date.....�1-�1.- ......... a y----- ,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-------____-_-__---_---_. rZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ cw ....r..............................................t -- ODescription of Soil ` =' .........fay v .a..............----------------------- •-•-------------------------- •----------------------------------------------------- •--------------------------------------------- •----------------------- .---•------.._._.. W V Nature of Repairs or Alterations—Answer when applicable..............................:................................................................ •-• -•-------------•---•----••••-•---••-••••••---•-------.....••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b i d by t �Vdh. i ... _....cg ........................... Application Approved By...._'................ ... Date Application Disapproved for a following reasons-----------------------------•-------•--------------------------------------------------.._......-----........ ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date V; No. Fps.....` f�............... THE COMMONWEALTH OF MASSACHUSETTS ,, --� BOARD F HEALTH /0-__j0,U.............OF......... 1.. -: ?. f: .-._::::.= ...-._................. Appliration for Uhipati al Worbi Towitrnrtion V rrmit Application is hereby made for a Permit to Construct ( `-ror Repair ( ) an Individual Sewage Disposal System at ...�� . ...... ..... m4l�./ -----...----••--•............................................................ yLocation- ress or Lot No. .......... ................................ ............................................... Owner Address :. ?1?!' -r------------------------------------------------ -------••----------._.............................---..............--------•--...-------•--•-..... Installer Address U Type of Building Size Lot_/�_ �A.Sq. feet 1—I Dwelling—No. of Bedrooms............... ...........................Expansion Attic ( ) Garbage Grinder ( ) �_l Other—T e of Building .............. No. of ersons...._..._..._.._.._..__.____ Showers a YP g .-----------•-- P ( ) — Cafeteria ( ) Otherfixtures -------------------------------•----------------------......------------------------------------. ................................. DesignFlow_.._____.__ _ gallons per person per y. Total daily flow..._3. -_-().._._.... ---------------•--- -- dons. W Septic Tank—Liquid capacity/ _gallons Length._ ._ .._.. Width................ Diameter................ Depth................ Disposal Trench—No..................... Width_�_. .._�f.._._.. Total Length.__........_... Total leaching area.................... -sq. ft. #'------------ I P --•- •. g r4r.W,0; t.'q. ft. Seepage Pit No. _ Diameter.__1} Depth below inlet__..0_.. Total leaching area Other Distribution box Dosingk z Percolation Test Results ) Performed by .. '.....r1___ __________________________ Date.._..�f C , --------' W a Test Pit No. I................minutes per inch Depth of Test Pit.................... Dept'i to ground water........................ ' rrX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground.water........................ .........................T__. _ _,........ r4 l_. :.. " : , ,�-�Ucf o Description of Soi .............. U •--•---•-••-••-----•-- -----•-•-------••-•---•------•-----•-••----••---•--•-•----•-. W UNature of Repairs or Alterations—Answer when applicable................................................................................................ •----------•---------------------------------------------........................................................... ---------------•--------•---------------------------------------•--------•.-----• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITS. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b i d by t - bo o th. n - e Application Approved B - -• -- ._------------------------------------•--•--------•---•-..........---•-- ..... A PP PP Y Date Application Disapproved f r he following reasons:................................................................................................................ -----•----•-•.......................•---...---•-------•---•---•---•-•-•-•------•-••--------•----•--•-----'--•-----•--•---•-----••----•-----•---------------•-••---••---•-•-----••------------•--•--•----- Date PermitNo.......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. fvlv',�J� .:.:.......r7a�.................OF....... ...... f .................... %lorrtifiratr of TompliFanrr T�H S IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by , "�� 5 ,,��. ...... ............---....... .----------------------------........---....----- . ....------......----........--•--...---------•-------.......... at.-- ._.t =-d-_.__{•• '-r---__�..�__�-- _p+'°"' _.=- "`-?_._._ 'Installer + 1 .............................................................................. has been installed in accordance with the provisions of TIT TR, of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.. " _"A................. dated_ 7_-�..':.1r A___.........._._... PP P _ __ -- --------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS D AS A GUARANTEE THAT THE SYSTEkI I L F NCTION SATISFACTORY. DATE._..._. .�:?. �3...................................................... Inspect ------•--•----------------------•-----....._._.._............---•-••-- Ya, THE COMMONWEALTH OF MASSACHUSETTS -� BOARD OF HEALTH .. 1 412w1(r/...............OF.-'-- � 'I• i �""._*' Z No. FEE. ................ Maps Workii Tutupwtion Vrrmit Permission is hereby granted--- ? ._. e ------------------------------------------------•------ to Construct ( or Rep 'r. ) an , di]Lid Sewage Qi osal System at No. ?c� = F . .....---- ••---....-- Street as shown on the application for Disposal Works Construction Permit No.�__.-!__'•_� Dat �_____Z......��.-..----.- y /O �/ ....................................... Board of Health ... DATE-------- -------- ------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS I .. - tAto 1' ZOO � °, . • �l � 6 A t' s 1� 155 z.4.` EKPA �0 GPI .0� - psT• NK IL _ Vl� o -1 2'' IC-ACHw6Pr> '° ► s' 5 9 0 �, v,� , t Q�(H DF/N•gSs Q) ALB T��• LO►rG c 0 E . �n (.:: 4, �J1N of�/S� Ak't--1 '. S, 00o S.F. pNo.11111�0 � OZ.� L'yG wt0Tl{ too ' AP ISTE� F�oNT s.R. 0 �FSSlONA1 LEGEND PLOT PLAN j EXISTING SPOT ELEVATION x0. ��o sv CERTIFIED . LO _ EXISTING CONTOUR --- 0 ---- Gp7-- �o vf= s .'ef'� FINISHED SPOT ELEVATION dS7 7ZW1L4_ } FINISHED CONTOUR - - O IN APPROVED = BOARD OF HEALTH , .• �����\,� ASL94blASS+ DATE AGENT SCALEI / "= 4D DATEl le OS7-. /A4E , 7?z, LDREDGE ENGINEERING CO! IN j CLIENT, I CERTIFY THAT THE PROPOSED c EGISTERE REGISTERED JO® NO, °`' BUILDING SHOVIIN ON THIS PLAN CIVIL LAND CONFORMS TO HE ONINO LAlls13 ENGINEER URVE pR,BY� •�: OF BARNSTAB f SS. 712 MAIN ST. CH. BY J fz, E • _ HYANN{S, MASS. SHEETJ_ OF 1 DATE G. LAND SURVEYOR . f 20 FT. M//V. /Y07E /F EITHER T/•NE SEPTIC TANK OR ' I-,E qCH//YG P/T AiTe MORE TH M.,V lZ••BELON/, /D /? M/N• GRADES A 24'�/i1 M ETER CONCR•�T� CONEr? SHALL B.E BROUGHT TO 4)TAAPE.,AIV EXTRA �- CONCRCTz q"PVC PIPE t/E,4 VY CA ST /RO/Y C 0 P-4-R L L DE 41 S EO M/N. P/TCN /F/N OR!VEN/A Y .♦• c L. 9 8 ,o COVERS I8"PFSQ FT 2 J MiN. CO/VCRFTE ,,oE L COVER CLEAN .SANG 0-CAS :•- _ UQU/D LEVEL •• : :.•.;�. IRON P/PE 19 y y • o'° QF /�8 ~*�8 'a: M/N.P/TGN G',L • 1 • ' " ' p yYASHFD SANE ' 4"PC/t/T NK D 1ST. V SEPTIC TA a A • • . . , . • • ► a , BOX v • 1 � � • • • • + .'p ° i b EFF�'CT/V2' • • ► • ° + • • DEPTH • • ' v WA5HED STONE -" i a o • • • • • • • • • ' o p o - ► n� a ► • • • • • • • • v •a p PRECAST SEEPAGE /NY�'RT ELEV.4T/DNS � ►s � • • • • � • • • • e o �2/7 OR E4U/V. 150. 8 x 2.S = 3�11 �.P. D. • a f=L= �9.0 lNYERT AT Q!JlLDI/VG r•O FT, 11 3• x 1 • O ' l i 3 G. P. D. 6 fT D/AM. INLET SEPTIC TANK g`�•S FT 12 F7 D/,4,W. C SEE7ABvLATION, OUTLET SEPTIC TANK FT. P'T c^PPc,r1 = 490 .P. D. ; INLET DI !/ STR/8T/ON BOX 93.9 ,C, SEG'T/ON OF GRDuNo WHITE TiaaLE 0U7LE7DI3TR/BIIT/ON BOX 9 3•7 FT. S� �GE O/.SPOSA l SYST�/�? INLET LEACHING PIT 23.D FT. TABULATID/V LEACH//V6 P/T 3 FT. DESIGN CRITERIA HUNGER OF BEVRoOMS 3 D/MENS/GN G-�-FT. M i� GAR�aGEO/SPO SAL UNIT o SOIL L4G TOTAL EJT/MATE.G FLOto(/ 3 3 0.4L.�DAY •SOIL TEST Al SOIL TEST#2 SD/L TEST .ti1UM8ER QF LE-AChIlNG PITS_/ f`ELE✓, g ro �`-ELEY, ,DATE OF SOIL TEST S/OB L EACH/NG PER P/T 150 g SQ FT. RESULTS 1 t/1TNESSEO 90TTOM LEACHING PER P/T 113. I W. A7- O _ Z PERCOL.• -r1oN RATE / «ss M/ INCH Z U.a ��. r8. ,�' TOTAL LEACH//VG AREA 2<03.9 SQ. FT. a/L )=ENCOLAT/ON RATE I 2 M1N.�lNGH RESERI�E LE✓4CH/NG AREA 2(-3.9 SQ. FT. •tom Zr -� Z / O5T. 11VV- 7 ,A OF /yoFn,,,�r MAD/ vim LUT 9 ovE�L. S ram . 40, r N ��, 2� A E c S/� N l� Q 5 TEjf' ✓/ L/-�' o ORSE c» No.10951 4) �� FL DREDGE hNG/NEER/lVG co"ING. / 4hIY Sr. p����� A9D�S 7/2 AS ONA \�` 8`3.� HYfiNN/.J MASS. j [8 NO GROUNQ y444TER ,ENCOU/VTERED r3 GMO UA/O kV.ATE.P AT EL EN. JOB NO. 0 0`f SHE.ET?OF �- �1./. .............. r THE COMMONWEALTH OF MASSACHUSETTSil� y ' 7 _9Ial = -3, 01P BOARD OF. I—IEALT �• ,�,., ���t 1_ ....................of.../ ✓.H.�. `... .._---_---- ` TITLE Appltration for Disposal WorksC�uu y �tr Tort hex tt � t, Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst at: ..... T .. .- ....--........ � ...��rs .... .�j��r � -------------------------------------•-------------------- ......... Loc 'on•Address. or t No. 1;�C/4---- ....... /O_wper /�� �/ A ress � Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms. l -.r..................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building .1V0.0_J?......... No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures --.................................................................................................................................................... W Design Flow.......!Y X ......................gallons per person per day. Total daily3�flow.._.7 ..._....................._...gallons. WSeptic Tank—Liquid capacity47iX;..gallons Length__..__..... Width...Y.......... Diameter................ Depth................ x Disposal Trench—No......I............ Width.................... Total Length.................... Total leaching area___.15_d.----sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) - '-' Percolation Test Results Performed by...2��d;4 ±r... ........•.. Date..... / --------- Test Pit No. 1_/:-_A...minutes per inch Depth of Test Pit.................... Depth to ground water.._`1 .. (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .......... ...... ..._.._:. ` - - --- - •----- . O Description of Soil••-fo..::,; f.....Zl. Q�---- ------------ •/---•-•----• �Vl '...... `tea' x W V Nature of Repairs or Alterations—Answer when applicable..______.-o I -------------------------------------------------•-•-------•-_-- ..-----••-••-•••••-•--•---•-•---•••--•................................-................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIL% 5 of the State Sanitary Code—The undersign d furtli agrees not to place the system in operation until a Certificate of Compliance has been ' s ed b ie ----------•---•---• ----- ............................. --•••- � . Application Approved By------- ------- - Gam?.._._._ Date Application Disapproved for the ollowing reasons:---•-•••-•-•....................•-••----••-•----••-•-••••-••-•••-•------•-•---•-----------...---•-•------------ ....••---....-•------•----------•....................•-----•------------------...._...........------.---_....---------_...---------•-------------••----•........_........----•------_............_....... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 ..................OF.... GIL!€t�T., ...................................... Trrttfirate of Tootpliattrr TV"' CERTIFY That the Individual Sewage Disposal System constructed ( or Repaired ( ) by - ----------------------------------------------------- - - at • f__.. ..............� --•------------------------------Z �es ------• ------------- has be in accordance with the provisions of TIGpTLu j of The State Sanitary Code to the application for Disposal Works Construction Permit No._S1'.--.':•��.............•... dated------- _. , _ ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector............................................................................ - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... .........OF... .......�'•............................................ Appliratiou for Disposal Works �un�frnr# pan rrutit: Application is hereby made for a Permit to Construct ( ) or,,_Repair ( ) an Individual ,Sewage.-Disposal System at: --------- ---• --- .. .................. Address� / j� or Ow per .....1_�?.......�cS! 1-- Address 1. ,Ow,�er Address a -J�: .... I-4e, ------------------------ ----------.--.---- .--.-_-------- Installer Address. < Type of Building Size Lot.................... .....Sq. feet �--� Dwelling—No. of Bedrooms._;_! ...................Expansion Attic ( ) Garbage Grinder ( ) �_l Other—Type of Building _lt1-Qom......... No. of persons............................ Showers ( ) Cafeteria ( ) Otherfixtures ----------•---------•---------•••-----•--•---••------•-•-•---------------•-•-•••---------•••-•-•---.....------...--•---••-•-- W Design Flow.......�,��� ......................gallons per person per day. Total daily flow.... 17v_............................gallons. WSeptic Tank—Liquid capacity Z2 .0 .gallons Length--- .._-..... Width.../.......... Diameter................ Depth................ x Disposal Trench—No......I............ Width.................... Total Length.................... Total leaching area....___�....sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tanlf ( ) '-' Ek Percolation Test Results Performed by.... Date Date..... __.._..__. / minutes per inch Depth of Test Pit.................... Depth to round water.._ _f!.. ...�✓h� a Test Pit No. 1. _.:s?„_ p p p g -%f� (.Tq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ LL' •..................... .............................. ----- _ . �"O Description of Soil....0. .'1�........ V ---------------- •--•--------------- ----------------- •---------- .-------------------- ------------- ••--------------------------W ••-•••-•--------------------••-----•---•-------•----•--------------••-••----------•----...••---....------------••------------••--••--- UNature of Repairs or Alterations—Answer when applicable._--__-,/f ............................................................... -•--------------------------•----....------------•-----------------•-------....-----.....---........--------•--------------------------•------------------------....................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersign d furtl: agrees not to place the system in operation until a Certificate of Compliance has been ' s ed t b e D Application Approved BY .. . -----•-•-----•----------•-•--•--•....................•-•-----•- ----•-- •..... ................... Date Application Disapproved for th llowing reasons:................................................................................................................ ----------------------------•--------•--------------------------•-------------•----------------•------------------ •----------------------------------------------------------------------- •-------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f1 !'rj.................OF...... : ��1 � (9rdifiratr of Toutpliattrr TII`' CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by.......... ......._ In ----- ---- ....................................................... at ----- '=e^"---------•--•--------------- has been ins ,lled in accordance with the provisions of TITLE 5 of The State Sanitary Code s ed in the application for Disposal Works Construction Permit `" ................ dated_... '''.+... .. ------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................•--•--..........----•--•-•-------.......------...._...._...... Inspector..................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.................................................._......................_........... No.. :. ..... FEE........................ iurou�t onsirion prrmff Permissionis he,eby granted............. "._ ....... .................... -------------•••-------------- •--••----•••-•--...----- •-----.....-•----••- to Construct ( or Repair k In v ual atNo.............................. •. Street yJ1 as shown on the/licat.'. for Disposal Works Construction Permit No-------------- ated.._._. ....... .........__............... ................................. ....... .......................................................... 2 oard of Health DATE.••• .......... ............................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS 1N Of �r a4 o vi 1! C a 4 O�STB�yp� ho sutw�j ,r y quo •, "N �,��' ��1; $ � { i p 4. no �` m P � Dom+•��1 � �°� � 6 - `\ ` � �- 1 m __DA dal x, �b. « V� • / (0, Ja y I CDC'�) •w I D7T4 ILC- Fl_lDI.S_T• I_LT (3ttc > to �.r. LEGEND EXISTING SPOT ELEVATION OAO ��" Mq CERTIFIED PLOT PLAN 01STING -CONTOUR _—. 0 ..,.._ .a�w FINISHED SPOT ELEVATION ,PI IILI © S E.NeE{ --'ET<'�✓I P'MIGHED CONTOUR ® �v R� y ;� •' ) No. 366�40 I N MOVED 1.®OARD OF HEALTH NAL fi +11�' s'STE NG��� 1 DATE AGENT BCALEt / "= 40 DATE' SLeT L t30tEDQE .ENGINEER/NQ-CQ CLIENTS I CERTIFY THAT THE PROPOSED lotE®PSiTE E CLI 9TERED d0® �10. BUILDING SHOWN ON THIS PLAN CIVIL AND CONFORMS TO THE ZONING LAWS V DR.By d4, �y OF* ,8ARN8TA E, �A88. 712 MAl N` STREET Cit By, cr M YA N N.1 S1, MA$3. SH S RL . G. LAND SURVEYOR — _ r ,..•. 4..44'.!9Y.!dt.:ahVrt.w:t'..;;Nw.b...4.:.:�...+e:...-.vwi.w....s ..n..:.....:.::.w... ....... .4.a.. .. .. .. •... .. ._ _ .. ... - .- /VOTE /F E/TNE.4 Ts,�E SEP7 TAN•l< OR20 AT. M/N. -� n'E/4C//ING PIT ARE r i= ^'JORZ TN A:/ /2" S'E O'kv 3RAOE, A 24'O/AM ET.ER CONCRETE COiiER S/,►ALL BE BROUGHT To 6RAoE. ��N EXTRA CONCRCTE 4PVC R/PE I t/ER{/y CAST /RO/Y CO{/ER L L !3E USES Ec -Y. ICD;.D. COVERS M/N. P/TCN /F/N DR/✓ElVA Y 2 '1. MAN. CONCRETE iA :•. ,. ir=r G '1DE CUYER . CLEA/V .SAND lieBACXF/L L 1 4"CAST 2'LAYER :.� /RON P/PE' b HIM.P/Tt/Il f G a 6A1- ": o • e o • • • • • •• • pP• h V 'Rem j-r SEPT/C: 7AM4K BOX ' ,o s . • • . . . ° • , • ;� WA S HPO 57t7NE e FECP•'. • r • o • • vpOpJ- +� • • • ° • v o lYA$NED STDrYE 3.7 7- • a. • • ♦ • • • • • • • p ••o PRECAS T SEEPAGE 3 1AIV&A-T &LZVAT/ONS P/ :x l.G. - - a�►•• • • • • • • a o P/T OR EQU/V. /NYERT AT 4L//LD/NG FT, PIT c¢f pA c,z ,` 9 0 GAS/f�.�Fry ° G D/AM. p /NLET.SEPTK' TANK ; —5 FT �Z FT 01AM. C.�SEE T�JVl-ATJ0*) O�JTLET SEPT/C TANK 3 FT. /NLET D/STi'�/BUT/ON BOX FT. SECT/ON 4F GROUND W,,4 elf TABLE No Yt EcEv BV.y� 0VrLET1D/3TR/B&4T/0N BOXY F7. %/VLEr 4rAcgj va /�iT y s:oFT SEls/AGE O/SPO�TA J. SYSTEM TASUL.4TlON L F—AC"IYVG P/T SCALE %4~ _ /=0~ D/ME/V.S/DA/ A 3 FT. DESlGJV .CRITERIA Ot►lExs/oN 8— —FT. N[lMQER OF BEDRaOMS 3 � D/MENS/ON C��.FT. �'n> >soY'r�+l� G�ROAGED/SPO.S.4L UNtT� 0 �. T0T.4G ETTLM�STED FLO*V 332 SOIL TEST G.4L.�DAY SO/L TEST Ak/ SO/L 71�ST�'2 iYUMBER OF LdACtNNG R/TS_. yG, -ELEY. Z �I S/DE L,.G'AOHING PER P_/T /S f SQ t=T. � ,DA TF OF SOI(, TEST %3 Q z RESC/L `TS iv/TNESSED BY BOTTOM Lle,AC'N/7VG PER P/T $Q, Ar L PERC0LA7-/0JT /IRTE,E! LCC-- IyIN•/INGH 7-07,1C LEACH,&Cr AREA ESQ, FT. r, PEltCOLAT'/oN RATE AZ �/�'�/y/N.�INCK RESERt�E LEAL'HING AREA Z1� SQ FT. o %O` s�'/L 4 F, LaAnj,il.J Pr c-pG�I t�P� ZN OF M, p�ZN OF L° 7 6 F L O v H o a�a� EL DREDGEENG/NEER/NG CO,/NC. N �BT �y0 SS/ONAIENG CLE1/; $�.`7 7/Z MAIN ST. • hHYANw/S, /MASS, SUS ND GROC/N[7 YV,4TG'R 1�NCOUNTER�O Q CL AF"r:L-S CouST DATE :2Ev. 01•ire-8 3 - C3 GROtivo LvATEMP AT ELE4! _ ��..Y i4, i9eti ✓OB NO.* B-49•A SHEET z-OF 2 i pL N o f SIC'?1 c. 5 r S E, ! _ DISTRIBUTION BOX SY►�� . {`,"' 1 , 9. �. „` , d dam'{ +) +.-, '9r.r f I e" fff / 4 ' 10 REMOVABLE COVER 4"SCH 40 OUTLET LATERALS TZyT PIT DATA I DISTRIBUTION BOX TO MEET SHALL BE SET LEVEL FOR A 15.232(WATERTIGH NESSSQUIREMENTS OF4,R FEET ANDMIWJMOCONNECTED TTHE FIRST O Performed By: Eldridge Engineering CONSTRUCtION•ETC1 2•' EACH DISTRIBUTION LINE WITH SOLID SCH 40 PVC PIPE 4"SCH 40 Date: September 21, 1981 NO.OF OUTLETS: 2 p o0 0 o — MECHANICALLY CRUSHED 6„(MIN) 6 c o oSrEQr�CC� TP-1 (EL. 97) � STONE k-3/4"DIA) 4 STABLE LEVEL BASE off - 24" Topsoil/Subsoil - -- --- �.Ja I 24" -144" Cl, Medium sand No Observed Groundwater � LEACHING DRY WELLS -5W GALLONS "END"CROSS SECTION PSOLalTIOid TEST DATA MODEL SHOREY PRECAST CONCRETE FINAL GRADE TO BE STABILIZED wr Date: September 21, 1981 I ` FINISHED GRADE(SLOPE - 02) j ! Sell Class: Class I (0.74 G/SF) =I I III 1Z'(MIN) III = 1 Perc Rate: < 2 MPI (TP-1 ) H -10 t o c LEACHING DRY WELLS , 2 o E X4'10"WXZ1"H o c ( cc d 1/4"-1/Z'DOUBLE WASH PEA STONE I SCSBDULE Oir ELEVATIONS OVERALL LEACHING AREA. 314" ) 1/?'DQU@LE ' BFN�Ni��Lk EXisT"6 1 25'LX12'WX2'H 'WASHED STONE ,400 EC.-foo*w BCE, �0° eri ! � Inv, Cut Foundation (existing) 96 . 6 �p �e� } 11, / inv. In Septic Tank !existing. 94 . 9 '* Inv. Out Septic. Tank (existing) 94 . 7 LFApIINGORti'WELLS L_� f ) Inv. in Distribution. Sox TO COMPLY'WITHTH 94 . 5u � r; _ E Q'`S`N�o REQUIREMENTS OF oA Cr, DECr i )Igo , Inv. Out Distribution Box 94 . 33 REQUiR 15 � I ' Inv. In Dry Wells 94 . 30 _ �x s Bottom of Dry Wells 9� . 30 Sottom(TP-. ) No Obs . G`+�1 (acprcx' ; ` !A' 3p r j ` i PkG-�t t Sr/N(6 1 La Ex7 sty ng Contour - - - �� wr NOTES �� P A<1 const-'u^tion methods sha cOnf;,r.: tc _he Tit-le S><4 �✓ _ _ _94 Proposed Con r our -MR 15, and � ( 310 / f, '+ the Barnstable Board of Health Regulations . Z -D�/ uJELi% t TaSrP4 tr h ere are 7 e a e no known pr4vate or public we within 100 I feet/400 feet, respectively, from the proposed ieachina I Finished Floor Elevation area . =here are nC known wet! thi n =G, ts,G {(STiNb I ands �!i _ �.�.. �� _ _ et of . - shc } Er proposed ' eaching area, nor is the proposed leaching area Basement Fl�t�r 1P.vat on B E within� t � �' t 200 feet c_ a river4zrant I Water Line "'--'W r: sting SAS to be pumped and removed prior to I _ _nstallin the new Dry ei , Q . �r wv,,o ,�,• i Gas Line 1 g y W -- . , 4 . No c;�,anges are �e y.y N � .. ,�I to be mar n the f= e ,` ,,u� t� va Tel Elec. and Cable - ---' `r', fi o?� the aoar. cf '.ea_ _.- and t:ie des � engineer. � _ � n h aocr--.. , { Proposed leaching area s not designed `or use w_r.. ! -- Gar:age -lisposai . \` 1 b. Contractor to notify Dig Safe 72 hours prier tc i construction. (800) 344-7233 . 7 . Property line 1 - _ i f P y information taken from Certified Plan Plat. \, rc ` y - * I 9 Lo e S Lane, 7S �] .�le I . pr�?oared rr „ t �•' ' i -�rns -b ie 'Lot_ 6 v l i ' L P,. , ` i E' *ou r o , o,o �.� .. lip Weinberg, P.E. and John Elias, R. L. S. Septic. Flan •o" �� +o '�Dt to be used as a property l;ne survey. I " caA410"1 I 8 . C:,)ntractor Shall JC'rlfy ail pl'1mbina from existing structure i OR Y r1/fM0T,4EN S, <� S C,i C S yS._.A Pc w. V i� a0 H RO !9 Ar "'PERT C 'Will be connected to the new « -�� t �•")n5trUCtlon. if any exiStina plutmnbincx exiting the „� o the tha _ shown or. the �r O S O i 1. t v o structure is found t� be dif_ rent DES►OS AL < r— N L. � t M jJp ARCA + ' y� >°;,� approved septic system plan, the c�ontrac.tor shall notify t'h 0� j�Pl t L S `r STEr 1 r It °*o c, t t.,�,rs w ^F?signe1 AL. �n r^al p_um g connected c new 5 S ; + MARSTONS ��s�"�,iA 1 L e ,z, n s a be t (-AL AS ff.�:,�n/ ----- f , ; E'�'t 5yst('m,�Un1E'S5 Ottlerw S�' S et:'--_ sE'� MILLS �R,11L1 DA MA�MA,J 3 dA CALCULATIONS 8ARTt[77 LD 1}E3l LQQ11)$ (EX1St LnQ j r»a`s0' 49 �s' 0 1.1� DIBdro4m X Bedrec:ms 330 Sri R 0' ^ < 94 �ti dt,vr,a,r p''' fit`~ �, rE?rc:.' ration Rate - < 2 MPI (TP-1) sAL~ c,x ass : Ci,3sS I (0. 74 C/SF) o"� CIP %0? ,,+' " •, j PROPOSED LEACHING AREA: IGlf ♦ �' t .r. r nr WA_ 1 _. a 25' L x 12' W x x?' Side Area: 148 SF X 0. 74 G/SF 109. 5 GPI ��. tA'ILI , y t �°v Bottom Area: 300 SF X 0 .74 G/S r 1 , a Tot a.. Lk aching Capes i t T4.,...1..5G prp r j\ T\r'• _— ; .ri QARyi s t f. �' d J� s a 9 4 xx4l�eof ' 3fl 1!>TA41 UT,ON � I -10 COELl�S 1 � r'KE'E'NSTrNIr I /U04 �4GLa� I SfFr�c r.�rrK I f a1 a i � I P Z O 0 8b fr W 1 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM d�-T•p,a ?P-1 CAL. = PS't, rr!R rir = No 105 Old East Osterville Road, Osterville rt�,T +'A g APPOAiE: ROVEDBY DRAWN BY LL — a _T r-----_— -OtSa 'tbQ Of7v C�� v 5+0Jo I E I 3 DATE:O+Oo oriD er�O pt3o pigo 1 /02 Daniel B Johnson D.B. Johnson #44110010d t1&i— Bomw (509) 420 - 3211 Per: 105 Old Lase Osterville Road, OsterVille, MR 02655 I r W Cr ( / Prepared Downfic SEPTIC DZSIQW, INC. (500) 420-1904 DRAWING NUMBER By: 804 Ma-IIn Stzwt, Suite B, Osterville, ra 02655 J-817 �7 ✓ i �r : t b s e t f > _ t t , j i - \ VA Is, • — — — e X 1,5 t i r f 9 q,-o to r-7 C/ P e-o f 1/e C... 7-1 o �\./ v E .0 T. S G.9 L E- / _ /O' w gas r4 i G STo tv 4 - -o —o—o—o- �rop05eo! grour7o/ IP-Ofi/e 1/O �E?/Z. 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