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HomeMy WebLinkAbout0047 OLD MILL ROAD - Health 47 OLD MILL RIDA b OSTERVILLE A = 141 043 I a � No. ""�/7�7 � �� Fee � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS infiration for Mioogar *pgtem Con!trurtton Permit 1. Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) 0 Complete System 1:1 Individual Components Location Address or Lot No. - Owner's Name,Address and Tel.No. OA �� vrTic 4A� Assessor's Map/Parcel ` /L 4 l G'� 4,2 p. ZIC Installer's Nactte,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: y0— 7 Dwelling No.of Bedrooms _ Lot Size' Y O sq. ft. Garbage Grinder( a Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow f/o gallons per day. Calculated daily flow gallons. Plan Date 6 a&a o/ Number of sheets 0Z Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) tJ.��,�! �,2��/,rd • G'.tt ✓�-�I .� ,k It-GZ , T o e:;:dLG a i'I ECG�G li /ti G �1�L+�/��.L✓,% r —d Siam r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t and of ea . Signed 's Date ,:C a Application Approved by Date Application Disapproved for the following reasons Permit No.idGrl� " �✓ �— Date Issued uu 4�y No. �Nb �. . Fee `�a THE COMMONWEALTH OF MASSACHUSETTS -` Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Rpprication for Oigogar *ps�tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel J� L ,L��iG C)li/il& Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size2,:�,, % U sq. ft. Garbage Grinder Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //0 gallons per day. Calculated daily flow J7 gallons. Plan Date G/-- } Jo/ Number of sheets r�2 Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 0 ��! st o f �J /r G'�c q X, °e` �� �G C __J o hle_,(r� Ly/l< ?' o Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by t and of ea Signed �, Date Application Approved by ' W Date OF Application Disapproved for the following reasons Permit No. '7040 Date Issued --------= ="1 ------------- -------- ———— - — T COMMONWEALTH OF MASSACHUSETTS B RNSTABLE, MASSACHUSETTS y CX /-f" S !l+SjkG7�'r I _'• _'�J Certificate of (Compliance THIS IS TO CERTIFY„that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by U�1,4 at 097XR4 �!!Pe ' has been constructed in accordance with the provisions of Title 5 and the for Disposal.System Construction Permit No. rVffdfated `°`17 Installer `' Designer The issuance of ermij,shall not be construed as a guarantee that the systa.) ill fu io desi-nea? Date Ql Irispe`ctor -- No. gooif, Fee d THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE., MASSACHUSETTS I=iZ po.5ar *pgtem Construction Permit Permission is hereby granted to Construct( )Repair(/�grade( )Abandon( ) System located at 92 o X 4 '''7 y J-j-ev 0 ; 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,ililrmit. Date: °� �! Approved b r 4 s� No. dpo— u Fee �Z/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(pprication for nigogar *pztem Construction Permit Application for a Permit to Construct( )Repair(i--Mpgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot 40. Owner's Name,Address and Tel.No. (� oZ 1't3 Assessor's Map/Parcel j A-1 0 1-1-3 tba h,to c —psT<, 1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. O �twce 81�oMs-� Type of mg: Dwellin No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or orAlterations(Answer w hen applicable) �\ j , " — 3FYOLw a 3V1 O tt�4'b l��to o Svr`\r-b0_o^a 0GPsI,S lacI�below ST n 1o,"3j-k C �Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu b this rd of H`e,al _ p Signed %� � e.�%C Date Application Approved by Date 7 - 3— o-w Application Disapproved for the ollowt g reasons Permit No. oZ.45V— Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(.Pl Upgraded( ) Abandoned( )by at '_� T O tC> kc:\l 21)(10— Q E has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer�r-cfcc �-(c�cc�((',�Ct Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector No. 3LtJ0 r c 1.4�~ x � Fee ` Ves�� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS k P ZppYication for Migoml *pztem Construction Permit Application for a Permit to Construct( )Repair(t.�pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �. Owner's Name,Address and Tel.No. 1 tt 3 0VI it (( <opt> - QS1C_r' L{ � \ACC_ �a. l-Svn Assessor's Map/Parcel / U ` h,k. t✓/YJG/i/ Installer's Name Address,and Tel.No. Designer's Name,Address and Tel.No. i S 1 • l q a� Qs\c.r,..ltc ��U'S5 Type of Building: �'.Rwelling� No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) 'k Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 30 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) G,�-­-"�Z ^�Q 15��' G��• e�\4� 1� �� &r�OLJ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in Acordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has,been iss,49d by this of H a Signed .- Date 3L, �Y 3 -0 0 Application Approved by Date 7 — S v e- r Application Disapproved for the followi g reasons lf Y .. Permit No. ;�Orn,— o�, Date Issued 4 r" l ..THE.;COMMONWEALTH OF MASSACHUSETTS �`"'l./B,ARNSTABLE, MASSACHUSETTS- (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( ) Abandoned( )by at L�-T Q\ \1 R, C 5 1 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. y _ dated InstallerSr-UCc �'tc_cc_(r, >�cc Designer The issuance of thi ernut shall not be construed as a guarantee that the system wiWfunction as)ddsigned./ '1/ � ; Date Inspector - "#� 1 - `t, df /', r --------------------------------------- No.�.( � — ✓��� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpooal *pztem Construction Permit Permission is hereby granted to Construct( )Repair(V_)'Upgrade( )Abandon( ) System located at Ltd O k IN 1 1 1 fC��� Cs N r c � y and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: -7 — O Approved by . AIN t u6i99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. � J �6L� 3 CER=CATION OF SKETCH —N-D APPLICATION FORA DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOIJ�"I DESIGYED PLA, S) hereby ce:-tiry that the application for disposal work construction pe,, -t signed by me dated conce- ina the located at .. property 41 �� O 1`( � � 1 20 - ©s�C�2�:1(E meets all of the following criteria: • The failed system is conne.^ed co a residential dweling only. i here are no c;,mme:cial.or business uses associated with the dwellins. • The soil is classified as CLASS I and the cercolation rate is less than or equal to 5 hunutes per inch. • 7here are no wetlands within 100 fee:of the proposed septic syse:n • Therc are no private wets within l:0 fee;of the oroposed septic slse n • There is no increase in flow and/or change in use proposed • There are no variances requested or ne`ded_ • i fie bottom of the proposed[eacaing faclity will not be loc;tted less than five tee:above the maximum adjusted.goundwater table elevation. [.adjust the zoundwacer cable using the F:impcor method when applicable) • Lf the S.A.S. will be located with 2-50 fee;of any vegetated wetlands. the boaorri of the proposed leaching facility will net be lccaced less than fcur-een 04) fee;above the mzurnurn adiused �*pundwater cable elevadon, Please complete the following: A) Tap at Ground Borate =i,—iauon(using GiS iniormauon) p2 e , 8) G.W. E'.diauon -the NLILK -igh G.W. Adjus-,ment . DT—FERE`+CE 3E i NEEV a,and 3 OCR) S1CNED : DA-L-E: c, 3-o 0 (Sketc`t procosed dart of on bac1j. q: caith iaidcr:cct 4• � y � r � o y� TOWN OF BARNSTABLE °`� LOCATION Al 7._ C.�_O ,r`��,t�©. SEWAGEjZaa`a VILLAGE ^s'2274..u/L ASSESSOR'S MAP & LOT INSTALLER'S NAME&PAONE NO. /,I a d `l SEPTIC TANK CAPACITY /! ra a LEACHING FACILITY: (type Z�3�a ����C dd1 1��(size) 5, Dee� NO.OF BEDROOMS aJ BUILDER OR OWNER PERMUDATE: ?/a COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet PrivateW Well and Leaching Facility an wells exist Water Supply g ty (If y on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of c n facili Feet Furnished by - �' — IL_ <. Z �3 j Al I? i ��, oZ s�oZ • _ y gY• y TfD'WO F B i 'f OLD LOCATION �' � RJR MWAGE 0 VlLLG U ° ASFSS®It'S MA'.d'i:1Ax__�__-.r' INS I �T. '51�TAI lit of NO S EP11C TA.NKC�#Cl.T �,K,der3 � '6 LEACgiT1�iCi_lE+A,.CII�..I`I"Y' ("ae) ( )•�--. Meld R+oOMs tart©v'nv -- - roc -DATE: 15pp eaora l c�; au 8ctweera:tx,1a Maximuml1}uatcclG1auttcly✓iital'ate(eta the Bottom 6fLaflc;hln ty. ..... .��.:. 1'aly t i/at4i;Sup�IY;VJoul a ct GaucW81,66,WfUasty�^�el9s c:x(st vne�t�s ai w3th�nOQ feat of lancEugi�r fstcil►tY) pcl�xc^ yf V�/et�aaat!acadLcaclt(����casity(iiE uiy wFUandS axi t . tvithu�3Q0 feet v anabaing Pucila °'t" �? eq ui�lshat0 IV A � G � 0 O � r L Commonwealth of Massachusetts .0/0 0 .� W Title 5 official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments" �M 47 Old Mill Rd Property Address Keith Byeriy Owner Owner's Name aj information is required for every Osterville MA 02655 4-30-16" s page. City/Town _ State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altererin any way. Please see completeness checklist at the end of the form. A. General Information ; 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S 13971 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5 (310 CMR 15.000).The system: ' ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluatio a Local Approving Authority 4-30:16 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 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•3113 * Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 t Commonwealth of Massachusetts r W Title 5 Official Inspection Form, o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments All47 Old Mill Rd Property Address Keith Byeriy Owner Owner's Name information is s required for ry Osterville MA 02655 4-30-16 �,� page. M, City/Town State Zip Code Date of Inspection B. Certification (cont.) S Inspection Summary: Check A,B,C,D or E 1 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: Y System is in good working order with no sign of failure. - t 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts 'x -'� • W Title 5 Official Inspection Form* ;t _ Subsurface Sewage Disposal System Form:-Not for Voluntary Assessments M s 47 Old Mill Rd ' Property Address ' Keith Byeriy Owner Owner's Name information is required for every Osterville' - MA 02655 4-30-16 page. City/Town t State Zip Code . Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will,pass with Board of Health approval if pumps/alarms are repaired. - B) System Conditionally Passes (cont.): T' • J x ' ❑ 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'inspeciion if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y , ❑ N i ❑,ND (Explain below): Elobstruction is"removed _{❑ Y4-❑. N . ElND,(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N' ❑ ND (Explain below): 4 ❑ 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): < t -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. I.'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 ` i J ❑ 1 'Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins"3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 3 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 47 Old Mill Rd Property Address Keith Byeriy Owner Owner's Name information is required for every Osterville MA 02655 4-30-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and oil absorption❑ y p s system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to-a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliforrn 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 El ® 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 Y2 day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts ` Title 5 OfficialInspection Form, _ Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments GSM ,•°'r 47 Old Mill Rd ' Property Address Keith Byeriy t Owner Owner's Name information is required for every Osterville - ' MA 02655 4-30-16 page. City/Town State Zip Code Date of Inspection r 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. ❑ ® y 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 i '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 a= e _ and chain of,custody must be attached to this form.] IT ,z The system is{a cesspool serving a facility with a design flow of 2000gpd- x 10,000gpd. - . i • -, „ 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. , ° , ° ,. .:.gin •. , . - i 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 1f you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form p . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 47 Old Mill Rd Property Address Keith Byerly Owner Owner's Name information is required for every Osterville MA 02655 4-30-16 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): 5 Number of bedrooms (actual)- 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins-3113 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Old Mill Rd =* Property Address Keith Byedy Owner Owner's Name information is Osteryille' 4 '. MA 02655 4-30-16 required for every - - page. City/Town State Zip Code Date of Inspection D. System Information Description: 4 Number of current'residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? 4 �. ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): ► Detail: _ Sump pump?' - > t.;. . . ❑ Yes ® No 4-2016 Last date of occupancy: Date Date Commercial/Industrial Flow Conditions: Type of Estabfishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) •' Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present?1- '` t. ❑ Yes ❑ No Industrial waste holding tank present? _ El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 47 Old Mill Rd Property Address Keith B ed Y Y Owner Owner's Name information is required for every Osterville MA 02655 4-30-16 Cit /Town State Zip Code Date of Inspection page. Y P P D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 1 Commonwealth of Massachusetts W Title 5 Official Inspection Fdrml Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 47 Old Mill Rd 1 Property Address Keith Byerty Owner Owner's Name information is required for every Osterville MA 02655 4-30-16 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: 2001 E Were sewage odors detected when arriving at the site? .- ❑ Yes ® No Building Sewer(locate on site plan): ' Depth below grade: c �,x - . 12" feet Material of construction: ❑ cast iron ® 40 PVC other(explain d its Distance frorm private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank (locate on site plan): 6" _ Depth below grade: `` ' feet ` Material of construction: - =' ® concrete ❑ metal ❑ fiberglass ; •❑ polyethylene ❑ other(explain) If tank is metal, list age: years -Is age confirmed by a Certificate of Compliance?-(attach a copy of certificate)' ❑ Yes ❑ No Dimensions: 1500 gal F' Sludge depth: 12" t5ins-3/13 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System-Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 47 Old Mill Rd Property Address Keith Byeriy Owner Owner's Name information is required for every Ostefville_ MA 02655 4-30-16 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 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts - w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 47 Old Mill Rd Property Address +` r Keith Byerly t Owner Owner's Name information is Ostenrille MA 02655 4-30-16 required for every - `•` page. City/Town i 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•3113 Titre 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts ; L r Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 47 Old Mill Rd Property Address Keith Byedy Owner Owner's Name information is required for every Osterville MA 02655 4-30-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from chambers. Pump Chamber(locate on site plan): Pumps in wonting order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Tithe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 47 Old Mill Rd • " Property Address Keith Byeriy Owner Owner's Name information is Osterville - :+ MA 02655 4-30-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) �. Type: ❑ leaching pits number: ® leaching chambers number: 5-500's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields '' number, dimensions: ❑ overflow cesspool r.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.): , Leach chambers in good condition and empty at inspection with no visible stain lines. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—,top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title_ 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. �M 47 Old Mill Rd Property Address Keith Byerly Owner Owner's Name information is required for every Osterville MA 02655 4-30-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy,(locate on site plan): Materials of construction: Dimensions , Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 47 Old Mill Rd ' Property Address Keith Byefty ' Owner Owner's Name information is required for every Osterville MA 02655 4-30-16' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) {• _ Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately i t s Y. i a. ' -0 5/d 1 , /7 6 -1 -F- r a 'A — t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i� 1' Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Old Mill Rd Property Address Keith Byedy Owner Owner's Name information is required for every Osterville MA 02655 4-30-16 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 47 Old Mill Rd Property Address Keith Byerly Owner Owner's Name information is required for every Osterville MA 02655 4-30-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System tge 17 of 17 OWN OF BARNSTABLE LOCATION ��-/ �tL.O 1 ZZ A_,�D• SEWAGE It, VILLAGE �SS�% /t &x/z e ASSESSOR'S MAP & LOTJ�� I�II INSTALLER'S NAME&PHONE NO. ��� ` i ��,�Y�f /.�f o b /d Ll' 1 SEPTIC TANK CAPACITY /` a a LEACHING FACILITY: (type �3 ya 6,AZ, C1.4 (size) I NO.OF BEDROOMS u� . BUILDER OR OWNER PERMITDATE; p?/-'2 r COMPLIANCE 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 Faeility(If any wetlands exist within 300 feet of c n facih11L Feet Furnished by , - --- PC � I � l -- w F.FEI;EV. 84 71 EXISTIN �� . r' BRING ONE COVER ELEV'. 83.5_ TO WITHIN 6 OF 20'MIN. , FINISH GRADE `4" CA37IRON OR CONCRETE COVERS ELEV.= 6__ SCHFOULE 40 P.V.C. / 4" CAST IRON OR SCHEDULE 40 P.V.C. DISTrI _ SLP. Q�_ 12" IN. 3" LAYER OF a INVERT • CONCRETE COVER SLP.= 0_0 f FLOW LINE DIST.=12.2 SLP. O._O1 — WASHED STONE. DIST.= 19.8 r ELEV Q ELEV.— — INVERT O O O�o o�O�o O d o 0 0-6-— --gV 0 0 0�0�0"0�0�0 O�o O�o.vovovovovovoy =8-2, 10" MIN. ELEV.= 81.4_ )o°o80°080°o°O°O°o°O°o° O O o 0 0 0 o O O o c -O_O_O_O_O_O_O_O._O_O_ - - ODODO O000O0OoODOoOoO, r 1,` THE LENGTH OF ELEV.= 81.79 ELEV.= 81.67 O 8" d O O u za" LAYER o OUTLET TEE IS B ELEV.=81_50 �0000000000000 ®®®® O ®®®® 0000000000000 /4" TO 1-1/2 DETERMINED BY THE 4" CAST IRON OR ®®®®®UE@000 O O O O O LIQUID DEPTH OF O O O O O O O O O O O O WASHED STON ,! THE TANK USED. SCHEDULE 40 P.V.C. DISTRIBUTION BOX 0000000000.000 ®®®®®®®®®®® 0 O O O O 0 0 0 0 0 o ELEV.=79.4 (SEE CHART AT RIGHT) LENGTH OF O O O O O O O ®®®®®®®®®®® 0000000000 LIQUID OUTLET TEE O O O O O O DEPTH BELOW FLOW LINE USE STONE 1500 GALLON SEPTIC TANK 4 FEET.......14 INCHES TO BE WET TESTED IF i TO LEVEL THE 5 FEET.......19 INCHES MORE THAN ONE OUTLET. 5 @ 500 GALLON LEACHING 4.0 TO BE PLACED ON 6' OF STONE 6 FEET........24 INCHES BED AS NEEDED- ` CHAMBERS WITH 3' OF STONE OR MECHANICALLY COMPACTED SOIL SEE 310 CMR TO BE PLACED ON ON ALL SIDES 1 15.227 (6) 6" OF STONE OR F _ _ _ —1— Pr } USE A TANK WITH THREE COVERS. MECHANICALLY COMPACTED SOIL. BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE ELEV \ SOIL TEST DONE BY: J.E. LANDERS-CAULEY P.E` A THIRD TEST PIT WAS EXCAVATED WITNESSED BY: D._MIORA_NDI CA ATED - -------- IN THE FRONT OF THE LOT AND PERCOLATION RATE: -2---MIN/INCH P# 9906, GROUNDWATER WAS OBSERVED AT TEST HOLE 1 DATE: 011101 _ ELEV._d;LC___ ELEVATION 72.0. PROFILE OF GROUNDWATER ADJUSTMENT CALCULATIONS `} DEPTH HORIZON TEXTURE COLOR MOTT. OTHER FOR THIS AREA BRING THE WATER LEVEL SEWAGE DISPOSAL SYSTEM - TO ELEVATION 75.3. NOT TO SCALE 0"-12" 0\Ap L SAND 7.5YR 4/3 1 HEREBY ATTEST CERTIFIED SOIL SOIL THAT ALA ES SACHOR . , GENERAL NOTES: ; , _' uLEY 12"-18" . B /M SAND 10YR 7/4 _____ `__ clvl� _- _ - ,1. THIS PLAN. IS FOR THE REPAIR OF AN EXISTING SEWAGE DISPOSAL SYSTEM. D '�GE��O\��a"`� ATE ,o� ME In 2. PLAN REFERENCE SEE SHEET 1 LOT 43 BARNSTABLE REG. OF DEEDS. NAL 3. THIS PLAN IS FOR THE INSTALLATION /REPAIR OF SEPTIC SYSTEM AND NOT TO BE USED FOR SURVEYING AND ZONING PURPOSES. DESIGN DATA: 4. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. NO 'H20 r. TITLE 5 AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS 18"-120" C M SAND 10YR 7/4 ENC D i FOR THE ,SUBSURFACE DISPOSAL OF SEWAGE. NUMBER OF BEDROOMS FLVE_G51____ 5. 'ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN TEST HOLE 2 DATE: 01111_(OL _ ELEV._83.3___ r '12" OF THE FINISHED GRADE. DEPTH HORIZON TEXTURE COLOR MOTT, OTHER GARBAGE DISPOSAL _X91JE-(9 6. EXISTING"AND FINAL GRADES SHALL REMAIN ESSENTIALLY THE SAME, UNLESS NOTED BY FINAL CONTOURS. J' TOTAL ESTIMATED FLOW Q__ GPD 7.• ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE 0"-9" AP L SAND 7'.5YR 4/3 �`� ( 11(L_= GAL/BR./DAY X �____ BR. ) OF` WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR SEPTIC TANK CAPACITY ,,SQQ�gI,-_ WITHIN 10' OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE "USED UNDER OR WITHIN 10' OF DRIVES OR PARKING ,, — AREAS ITINLESS NOTED. LEACHING AREA REQUIREMENTS 8. .ANY MA-�ONARY UNITS USED TO BRING COVERS TO GRADE SHALL 9"-27" B F/M.SANE 7.5YR 5/8 RTARED IN PLACE. SIDEWALL AREA _24L 2 GAL/S.F. v 9. N ) DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH BOTTOM AREA- _ 3Q9 GAL./S.F. DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM APPROPIATE AUTHORITY. ! LEACHING CAP.(BOT. & SIDEWALL)- 575 - GAL 10. THE EXCAVATOR/CONTRACTOR SHALL VERIFY THE LOCATION OF ALL UNDERGROUND UTILITIES_ PRIOR TO ANY EXCAVATION. 27"-120" C M SAND. 10YR 7/4 NO ^H2O. RESERVE LEACHING CAPACITY _575 GAL ,. EVC'D APPLICANT: KEITH I3YERLY and ANN KELL DATE: 01/22/01 _. ! SHEET 2 OF 2 JOB # 978 h+ r E 'i LOT "A» w .FINGER _ y LOT B L`�NE z t7 orti °§ LOT „C" co 00 J i - 9 ga , ' NOTES: , THIS PLAN WAS PREPARED FORM AN ON THE GROUND CAPE COD / - lb , INSTRUMENT SURVEY. THE PROPERTY LINES WERE HORTICULTURAL _ ESTABLISHED FROM THE RECORD PLANS AND DEEDS SOCIETY Epp �` ,' f� / ,' 40 ' /EXISTING LISTED BELOW: PIT C`l � PLANS DEEDS / (SEE NOTES �ti BOOK PAGE BOOK PAGE 55 125 746 256-257 92 65 8890 299 g ' j / 198 11 9055 82-83 c / / / / PAVED DRIVEWAY ' 278 47 13216 317-319 'LOT 43 i _. '_- ._ Y� 1`- }� - ' 79,490f S F' -_ , / _ 371 49 / p i ( I I LOT 43 IS SHOWN IN THE C & B FLOOD ZONES. dgy� o, ,�' / ;;; ,,,,, \\\\ LOT 43 IS SHOWN IN THE "RD-1" ZONING DISTRICT. LOT 43 IS SHOWN IN THE "AP" GROUNDWATER PROTECTION OVERLAY DISTRICT. ' %b0• -� o ® - ' ' ICI?' / W THE EXISTING LEACHING PIT IS TO BE PUMPED AND FILLED WITH CLEAN INERT MATERIAL. TP y ` O / 78 / TP o4b JON � LOT 41 � 1 �� ,i ® �s LEY i> 3 01 / )A4 _.. 1 Q4 SITE PLAN / PREPARED FOR j/LOT 42 KEITH BYERLY and ANN KELLY OF #47 OLD MILL ROAD BARNSTABLE, MA J.E. LANDERS—CAULEY, P.E. CIVIL ENVIRONMENTAL ENGINEERING P.O. BOX 364 WEST FALMOUTH, MA 02574 (508) 540-7733 ph. (508) 540-3022 ph. 508 540 — 3344 fax ASS. 141-043 DATE: 01122101 SCALE: 1" = 30' DRAWN BY: JDR JOB NO. 978 SHEET: 1 OF 2