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Home My WebLink About0102 OLD MILL ROAD - Health 102 Old Mill Road Osterville CP/R r A = 141 051 ... TOWN OF BARNSTABLE CaV,4 V> t-n t-4 A L LOCATION 1 Da V/�l e SEWAGE # 44 Zl l b 4 A-�LLAGE OSTw ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY C2SSp�o LEACHING FACILITY: (type)- P/-' GX (size) NO.OF BEDROOMS 3 BUILDER OR OWNER C- V U.SC 0 ! -` PERMITDATE: COMPLIANCE DATE: Separation Distance Between the ICI QZ�S Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility'� �' N' 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 cility) Feet Furnished by Ti►s�e�`,on �� 0/tJ 3y aS �k a� �` Commonwealth of Massachusetts A W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �H 102 Old Mill Road Property Address Kukoleca Owner Owner's Name / information is required for every Osterville ✓ Ma 02655 8-23-16 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, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation r� Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number i B. Certification 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 8-23-16 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. I ' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 � 6 y �s Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 102 Old Mill Road Property Address Kukoleca Owner Owner's Name information is required for every Osterville Ma 02655 8-23-16 page. City/Town State Zip Code Date of.lnspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working order at time of inspection. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I I - - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments �.w 102 Old Mill Road Property Address Kukoleca Owner Owner's Name information is required for every Osterville Ma 02655 8-23-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 102 Old Mill Road Property Address Kukoleca Owner Owner's Name information is Osterville Ma 02655 8-23-16 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �nM 102 Old Mill Road Property Address Kukoleca Owner Owner's Name information is required for every Osterville Ma 02655 8-23-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No j s ❑ ® 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. j ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins•3/13 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 � 102 Old Mill Road Property Address Kukoleca Owner Owner's Name information is required for every Osterville Ma 02655 8-23-16 page. Cityrrown 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): 331.8 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts =i F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 102 Old Mill Road Property Address Kukoleca Owner Owner's Name information is required for every Osterville Ma 02655 8-23-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection, ❑ Yes ® No information in this report.) Laundry system inspected? Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2014-90,000gallons 2015-70,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: 8-20-16 Date Commercial/Industrial Flow Conditions: Type of Establishment: NA 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M0 102 Old Mill Road Property Address Kukoleca Owner Owner's Name information is required for every Osterville Ma 02655 8-23-16 page. CityrTown 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: Owner—.last pumped March 2016 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 102 Old Mill Road Property Address Kukoleca Owner Owner's Name information is required for every Osterville Ma 02655 8-23-16 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 34" feet Material of construction: ® cast iron EA0 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan); Depth below grade: 2 8 feet Material of construction: a ® 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: 1500gallon Sludge depth: 3" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 102 Old Mill Road Property Address Kukoleca Owner Owner's Name information is required for every Osterville Ma 02655 8-23-16 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 1 ` 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): �Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: l Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 102 Old Mill Road Property Address Kukoleca Owner Owner's Name information is required for every Osterville Ma 02655 8-23-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA 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.): r *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 102 Old Mill Road Property Address Kukoleca Owner Owner's Name information is required for every Osterville Ma 02655 8-23-16 page. Cityfrown 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 11 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.): D-box was in working order with no signs of back up or carry over. 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.): NA I * 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: i t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 102 Old Mill Road Property Address Kukoleca Owner Owner's Name information is required for every Osterville Ma 02655 8-23-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries J number: ® leaching trenches number, length: 37'x10'x1'with infiltrators ❑ 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 was in working order at time of inspection. Leaching was dry when inspected. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 102 Old Mill Road Property Address Kukoleca Owner Owner's Name information is required for every Osterville Ma 02655 8-23-16 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: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CCG9M 102 Old Mill Road - - Property Address Kukoleca Owner Owner's Name information is required for every Osterville Ma 02655 8-23-16 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 FRONT _ ._ .... - l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 102 Old Mill Road Property Address Kukoleca Owner Owner's Name information is required for every Osterville Ma 02655 8-23-16 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope Surface water ® Check cellar ® Shallow wells No GW 144 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: May 18 2004`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: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 102 Old Mill Road Property Address Kukoleca Owner Owner's Name information is required for every Osterville Ma 02655 8-23-16 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-Page 17 of 17 TOWN OF B' STABLE �a )CATION �� SEWAGE # —� V -LAGS Vi�%�[)� 1' — ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY V LEACHING FACILITY: (type) �'� �i�1-- (size) -.,NO.OF BEDROOMS BUILDER OR O R hJ PERMIT DATE: OMPLIANCE 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 :x 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 �CZA/I 3, 16C T C-.I I . DST No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BAR�STABLES MASSACHUSETTS 01pprication for 0 gponl *pgtem Congtructton Vertu Application for a Permit to Construct( . )Repair( Upgrade( )Abandon D<Complete System ❑Individual Components Location Address or Lot No. l 02 Old M%1� I OSrkN�lk Owner's Name,Address and Tel.No. :�C� Cx1SCA� Assessor's Map/Parcel I[ J OS I c�M Installer's Name,Address,and Tel.No. tak}g-5310 Designer's Name,Address and Tel No. —ca 1�' ab2c'ts sap",0 SOCUICGe Saco? fsro%cv,-N + Ncts 4J,jC.S,1ne_ c Tcft-JA N_S°t•) qcc.m o,&vh tmc' eQ•o•'5OX to IN .F'Qk t-no.W,. M$N Type of Building: 2 Dwelling No.of Bedrooms 3 Lot Size 3J,' 6sq.ft. Garbage Grinder Other Type of Building ww E No.of Persons oZ Showers( V1,etena Other Fixtures LOA_V ht:O� iz tC.�� S\nk L_�C) � Design Flow gallons per day. Calculated daily flow r2� • gallons. Plan Date Los ` (a 104. Number of sheets I Revision Date Title SabSv C!;c C.e T\ Size of Septic Tank l S oO ��N Type of S.A.S. 16, 3-was Clr. S Tr► �:l-1r+c� e-s Description of Soil Nature of Repairs or Alterations(Answer when applicable) A56Nm Nib Dull 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 provisi ns of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has b is e, this Bo H t igned Date Application Approve Date Application Disapproved for the following reasons Permit No. aQpie- as Date Issued C � N � � f 1 .,, � '�. — � ` _ --�o,�. Fee ,, - Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS" Yes. 4PUBLI6 HEALTH,DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS Application for Migahl Opmem Congtruction Permit Application for a Permit to Construct( , )Repair(><Upgrade.( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. O t� ralc\ 1 r\1 Kc�i C''S "ur 1\e Owner's Name,Address and Tel.No. Assessor's Map/Parcel I�`� ' 1 VSsA e Installer's Name,Address,and Tel.No. 1 lA L116_51N O Designer's Name,Address and Tel.No. \y 1 V%C�E' tCy?Cl n1Q,�l \C r Q C �- rJ oo Type of Building: Dwelling No.of Bedrooms Lot Size F Lsq.ft. Garbage Grinder(dla, Other Type of Building CAP,\ No.of Persons c� Showers( Cafeteria Other Fixtures ,>�� tC\�zc• knlIC- Design Flow gallons per day. Calculated daily flow gallons. Plan Date 0 Number of sheets a Revision Date Title Ct:(�� C� 'y�? u CC5� et;5c1 `Jv,Sy, �T Size of Septic Tank ( 0o \\t:)0 # Type of S.A.S. Description of Soil "�0 �I7i'ffi 1p�4r,. t ) Nature of Repairs or Alterations(Answer when applicable) �� 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 provisi ns of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance hassbb . i edtbVthisoar o iS gned / (/J Date Application Approveli-by _ Date r Application Disapproved for the following reasons Permit No. 4 GC'�' Date Issued i THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO 4CIFYZPat the On-site Sewage Disposal System Constructed ( ) Repaired 0UpgradedAbando e ( byS at � LiUQ r 5flYV1 It e-, has been constructed�in /accordance with the pr1°w�i�ion Aof�Tit/le 5VA e f1o�r�is al System Construction Permit No. �UOq -a��dated ' /b�� t Installer MO, / _ / t/C Designer e-. �4 n The issuance of this permit r a 11�o be #rued as a guarantee that the syiem) 'rlv�fu�nlcti/off a ders' ned1 Date Inspector �D�� r- V ; G -----------------------------— 570 _..— No.o. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ;igpoga[ *pgtem Congtruction permit Permission is hereby g an d�p jC9nstr ct ��)R- i Up ad A/bapd�on( ) System located at 7� (J/L( / V �-- 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:Const ccrtionrpmuus't be completed within three years of the date f this /_'t: Date:_ f 7 Approved by �i Town of Barnstable , .OPINE r Regulatory Services Thomas F. Geiler,Director • BARNSF4iB3 9�A MASS. Public Health Division tFD �s Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 I Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: l Designer: Installer: Installer: CSC , Address: o -6aX Address: On �5 p C� S "C was issued a permit to install a (date (installer) septic system at 109L n' A MI I I _J�A , based on a design drawn by (address) �DU\VMfYoflkX5 0Mated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. C o CARMEN �N ` (Installer's Signature) E. co SHAY No. 1181 rn .p o L FerSt�R —(Designer's Signature) (Affix Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE :ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form TOWN OF B STABLE le: C'' LOCATION �J r y SEWAGE # — VILLAGE SESSOR'S MAP & LOT AME&PHONE NO` - INSTALLER'S N 1_ SEPTIC TANK CAPACITY LEACHING FACILITY: (tyke). '`—t � L' (size) 3? NO.OF BED90OMS BUILDEROROWNTfR PERMIT DATE: OMPLIANCE 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 Feet on site or within 200 feet of leaching facility.) Edge of Wetland and Leaching Facility(If any wetlands exist - Feet within 300 feet of leaching facility) Furnished by Alt DST 6,D>° Sep - 20- 02 13 : 52 BARNSTABLE HEALTH OEPT 5087906304 :NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATIO:N TEST AND SOIL EVALUATION EXEMPTION FORM gfjG—� 1A� hereby certify that the engineered pian sip ed by me uatec Jr 1 O , concerning the property located at _InZ a\d M:\IUj OS �C`V� �� meets all of the (c[lowtn; crttena� This failed system is connected to a residential dwelling only. There are no .ommerzia! or business uses associated with the dwelling, 7'.e soil is ciass:fied as CLASS I and the percolation rave is less than or equal to > n.nutes per inch. The applicant may use historical data to conclude this fsc: Jr may _onducc are!tm,;,ar% tes:sa( the site without a health agent present • here :s no incrta.c in flow and/or change. in use proposed i here are :to variances requested or needed. at • The bottom bf the proposed leaching facility will not be located less than fourteen 'ee: aoove the maximum adjusted groundwater table elevation. (Adjust the ;rnunc! wi, table using the Frimptor method when applicablef Pease complete the following, �. Ground Surfede E:evasion (using GIS information) F' G.Vr' E!evat,or, 15 _ ,d;us(men( for '.-iigh G.W. BETWEEN -\ and B S UVED _ DATE: _------------- ._.._— ,NOTICE ' 3asec ,-On the above ir.formation, a repair perrru( wil! be issued for -)edrooms bedrooms are authorized to t`te future wi.how en,tncerec , :e�syste-n plans. )calf•!r4cf Pcicc.tmq r— Permit Number: Date: Completed by: HIGH GROUNDWATER LEVEL COMPUTATION Site Location: (02. C�1d M•�1 ��5 �]�11Q , � Lot No, Y Owner: CJe_oM Z (n'ISS(b* Address Contractor: � � fti'Q,rS�IU.� Address:�X (pa3,— to, FO,J(7Y)6LrK kA , Notes: �,Q V STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. .Date mon h/da /year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well.................................................... OWater-level range zone ..................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... mo th/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water level zone (STEP 2B) determine water-level adjustment ........................................... .. .................... ................... 0 STEP 5 Estimate depth to high water by subtracting the water• level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ........r.........................................'• Figure 13.--Reproducible computation form. 15 j COMMONWEALTH OF MASSACHUSETTS P EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP 141 PARCEL LOT 4 TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION I Property Address: 102 Old Mill Road Osterville, MA 02655 Owner's Name: Carrie Guscott Owner's Address: 26 Elm Hill Avenue Boston, MA 02121 Date of Inspection: April 12, 2004 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the intjormatio&�;-kpor l below is true,accurate and complete as of the time of the inspection. The inspection was performed based�ti my f training and experience in the proper function and maintenance of on site sewage disposal syst 1= . I am C) 4 approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sy3 m: O co o a' Passes �= ✓ Conditionally Passes W Needs Further Evaluation by the Local Approving A thority Fails cn r*� Inspector's Signature: Date: April 13, 2004 The system inspector shall subm4 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. 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 page 1 I Page 2 of 1 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 102 Old Mill Road Osterville, MA Owner: Carrie Guscott Date of Inspection: April 12, 2004 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: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined.(Y,N,ND) in the for the following statements. If"not determined", please explain. ✓ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or 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. NOTE: Cesspool is acting as a septic tank. Cement blocks are deteriorating and the cesspool is structurally unsound. Cesspool needs to be replaced with a septic tank. 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): brokempipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 102 Old Mill Road Osterville, M4 Owner: Carrie Guscott Date of Inspection: April 12, 2004 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: ;r 'r 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 1 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. I The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. r 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 DO 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: 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: 102 Old Mill Road Osterville, MA Owner: Carrie Guscott _ Date of Inspection: April 12,_2004 D. System Failure Criteria applicable to all systems: You must indicate either"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 %z'day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed_ pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 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.] No (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 System: To be considered a large system the system must serve 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered '`yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 102 Old Mill Road Osterville, M4 Owner: Carrie Guscott Date of Inspection: April 12, 2004 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: Yes No ✓ 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(3)(b)]. 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 102 Old Mill Road Osterville, MA Owner: Carrie Guscott Date of Inspection: April 12, 2004 FLOW CONDITIONS RESIDENTIAL M Number of bedrooms(design): n/a 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: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): Yes [if yes separate inspection required] �.. Laundry system inspected(yes or no): No(Could not rnd-needs to Ye-hooked up to main system) Seasonal use(yes or no): Yes Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown f COMMERCIAL/INDUSTRIAL Type of establishment: .Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,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: Unavailable Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed.(if known)and source of information: A leach pit was installed on 5121174-per as built card Were sewage odors detected when arriving.at the site(yes or no): No 6 f Page 7 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 102 Old Mill Road Osterville, MA Owner: Carrie Guscott Date of Inspection: April 12, 2004 BUILDING SEWER(locate on site plan) Depth below grade: 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 on site plan) (Cesspool acting as a septic tank) Depth below grade: Cover to,grade Material of construction: _concrete _metal _fiberglass _polyethylene ✓ other(explain) Cement block If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: S'W x 5'T x 8'bottom to grade Sludge depth: -- Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: -- Distance from top of cum to top of outlet tee or baffle: -- Distance from bottom of scum to bottom of outlet tee or baffle: - How were dimensions determined: Measuring 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.): The cesspool was dry. The cesspool was made of cement block which was deteriorating. The cesspool needs to be upgraded to a septic tank. GREASE TRAP: None (locate on site plan) 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.): 7 I Page 8 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: .102 Old Mill Road Osterville, AM Owner: Carrie Guscott Date of Inspection: April 12, 2004 TIGHT or HOLDING TANK: None (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: izallons 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: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (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.): 8 • 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: 102 Old Mill Road Osterville, MA Owner: Carrie Guscou Date of Inspection: April 12, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 - 6'x 6'(1000 gal.) 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.): The was dry. The scum line was approximately Y up from the bottom. There did not appear to be any signs of failure. The bottom to grade was approximately.9'. A video camera was used to inspect the pit. CESSPOOLS: None (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: None (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.): 9 Page 10 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 102 Old Mill Road Osterville, MA Owner: Carrie Guscott Date of Inspection: April 12, 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �SS1 �1 Iy 3y as 10 Page I I of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS .SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 102 Old Mill Road Osterville, MA Owner: Carrie Guscott Date of Inspection: April 12, 2004 SITE EXAM I Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20 +/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximatel v 20'+/-to ground water at this site. This report has been prepared and the system inspected and conditionally passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. Il Y 193 L O C_QT_LO N ; SEW_ _4_C�E E.RMIT--M 0- g 1-. ---T-A. _13 I -w. .i ' a r �� .. - � . , _ r � V No......193 Fit it�.'—'............. THE COMMONWEALTH-OF MASSACHUSETTS r BOAR OF HEALTH _._..... .... ._ - -- ..OF.......................................... .. ........ Appliratiuu -fur Uiipufiat Works Towitrurtiou 1jrrmit Application is hereby made for a Permit to Construct ( ) or Repair (4+ an Individual Sewage Disposal System at: Loc ion-Address or Lot Ivo: ------------------- W — O Address F„� •- -•- --""--��"�---------•--•-••-----------•- Installer Address Q Type of Building Size Lot----------------------------Sq. feet U • Dwelling—No. of Bedrooms__ _____________________________________.Expansion Attic ( ) Garbage Grinder ( ) a4 Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width.__-____._.. Diameter..........------ Depth---------- x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area.-----------------sq. it. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------------------ ------------------------------------------------------- Date--------------------------------------- ,� Test Pit No. 1----------------minutes per inch Depth of Test Pit.............._----- Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.--------._.______-- Depth to ground water-._-.----------_--__.. ---------• --------- ------•-•------...._.....-------•---•----------------------••--•••--•----•--••......................................................... 0 Description of Soil------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------- x U -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W ------------- -------------- --- ------------ U Nature of Repairs or =ltera • ns.—Answer when applicable._. �9--- �...... ..____..... -•--....--••-•------•------•---------------------- .._.. Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code— The undersigned further agrees not to.place the system in operation until a Certificate of Compliance has baernissued b the boa1A of ealt) / V Signec>,�, -�� =�--- ---- ------ �` !-`-= 1 --- -..... `4 Date ApplicationApproved By--------- ---------------------------------------------------------•------------------------ Date Application Disapproved for the following reasons:----•---------•---•----•-•-•-•--•--•-•--•..................•-•-------------•--•-................................ --•-•------------------•----•------••--------•---•---•--------------•--....----------•-•---------•------•..-----------.................-----•---•--••-•---•-----•---------.....--------...---------•-•. Date Permit No.........1-f-3----------------------------------- Issued...........j-�:27'--7 Y.... ............. Date 0 No....... ......... Fps .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........OF........................................................................................ Appliration -for Diapviial Vorks Towitrurtion Prrutit Application is hereby made for a Permit to Construct or Repair (k+ an Individual Sewage Disposal System at: -------------------------------------------------------------------------------------------- .... ............................ Localnion•Adflress or Lot No9wpwAWAA" 0 ...... . ..... .......................... ...I ---e4r_944A&Y. .......................... . ......... 0 e Address ..P. . ..................... . ........... .................................. ................................................................................................ Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.--- --?-----------------------------Expansion Attic Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons_.__._.._.._.___._....___.. Showers Cafeteria ( ) P4Other fixtures -----------------------------------------------------------------------------------------------------------.......................................... Design Flow.......................................%.,...-gLllons p�r person per day. Total daily flow--------------------------------------------gallons. 1:4 Septic Tank—.Liquid capacity------------ga'llons ;,,Length________________ Width..__........._.. Diameter_..._.......____ Depth.-.----__-.----- Disposal Trench—No- ____________________ Width:________.._..______ Total Length:-_-_____:_______-.- Total leaching area--------------------sq. ft. Seepage Pit No_____________________ -------------�7il,.... Depth below inlet................. Total leachino, area------�:........ it. Z Other Distribution box Dosing J4Pk_.(.,'%). Percolation Test Results Performed by.-..-'!*------------------ ........................... .............. Date.._.._..._._...._..__......_______...:.. Test Pit No. I-_------------minutesperinch Depth`of Test Pit..................... Depth to ground water....-------_-------.....- 0:4 Test Pit No. 2................minutes pen inch Depth of'ftst Pit.__________________. B;p�-,to ground water-... P4 ................................ .1 ........................................ ................................................. ............................ 0 Description of Soil----------------------------------- .............................................................................. ------------------------------------------------------ U ............................................................................................................ ..................................................................................... ----------------------- ------------------------------------------------------------------------------------------ ---Zj� ........�.. ...... ............. U Nat re of Rep�air,or Ateratlon*—Answer when applicable.- -- ---- -- ---- - ----- ---------------------- __ __a , In,447R.P.. 47"Wo•.............................................. --------------------------------------------------------------------------........... Agreement: ' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has issued.bb the board of 1;ealtp Signe . .... Application Approved By--------- I/I/ Date — . . ............................................................................ ....................................... Date Application Disapproved for the following reasons:..................................................................... ................It........................... ......................................... ........... .. ,�.............; ........... ................................................................................................................. Date Permit No--------Y1 3.................................... Issued............ .................. Date THE COMMONWEALTH OF-MASSACHUSETTS i. BOARD OF HEALTH ............ .............OF........... .........5 ........ Qlatifirate of Tomptiana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by.............Iq-�.-6............ ........................................................................................................................ Installer at............../, ....................0_44�... ------A-41--------------------------------------------------------- ................................ -------- has been installed in accordance with the provisions of Article XI of The State.?Sanitary Code as described in the application for Disposal Works Construction Permit Igo 1 .............----- dated.-..__ .................. THE ISSUANCE OF THIS CERTIFICATE SHALL'140T BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----- ....J'...- ..............- ---------------------------------------- Inspector........ ................./---------------------------------------------------- -j THE COMMONWEALTH OF MASSACHUSETTS ? BOARD 0 E+� &iALTH A- .........OF..... .............................. .............................:/................................... No.__... FEE........................ . rhat Permission is hereby granted------------Af 4................................... ............................................................................ to Construct ) or Repair (4*y`a_n Individual SSwage Disposal System atNo..........&.0........ ..... .. . ......... k'/4e....................................................... Street as shown on the 4pplicati�iffqr'Disposal Work's"C-oifg�rpction-"Rer-mit No--- ......... Dated....... ........... �A ....................... .............. ............................................. DATE----- --- --------------------------------------------- Boar Health FORM 1255 1HOBBS & WARREN. INC.. PUBLISHE.k§V 1�k �ii / -Y""/ � ,. �j .� .. �»u �� :. : . i 3-24' DIAM. ACCESS MANHOLES doJU •m` t o s VENT PIP (O east 4 Inches tall) 10, -8 NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. vE E d L 2s D , 10' min. from Schedule 4 PVC w/Charcoal Odor Filter I SECTION A -A :�r. -° ,_::_,i„i ', :�' :is '':i ?{ , ,(" i �,n J• e, -� 'k;, `S house to septic tank PROFILE VIEW OF ADDITION TO LEACHING SYSTEMExisting Foundation 9 Septic tank coven must be •.� I 1 1; �je 1 Yyt T.O.F. elev. - 100.00 within B in. of finished grade Ode over 5AS - 98.00 3" of 1/B- - 1/2" Washed Peastone ,, `. Grade over Septic Tank - 98.00 Grade over D-Box - 98.00 3/4" to 1 1/2 " Washed Crushed Stone INLET / 1 ,17 ow-iA\ INLET n OUT ET S - 0.02 I 4' PVC(CAPPED)INSPECTION PORT TO BE 'Y• THE ACCESS COVERS FOR THE SEPTIC TANK, y ,1 102 014 MM FA� �c f � Top Load - Elev. -94.75 J DISTRIBUTION BOX AND LEACHING COMPONENT INSTALLED AND TO BE WITHIN 8' OF GRADE .? � � JE : (H-20)DIST BOX Top of SAS - Elev. -04.25 I '` H R D TO WITHIN 6 OF I� f nae` r - 5-0.01 a Greater ..r S ALL BE AISE • FINISHED GRADE. EXIST, PIPE NNEW 1,500 GAL t0, 10' foot 0' Effective Depth FROM FOIMDATXN �CSEPTIC TANK RNSMISTEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITE GAS BAFFLES OR EQUALS H-10 00 20 ON ALL OUTLET TEE ENDS a .-...�. 5 Units 2 6.25' - 30' PLAN VIEW > 0.83' (10 inches)CONCRETE FULL fOUNDATIO A vi rn r7 ati rn 3' 3' 3-24• REMovaeLE CovErts IOC enj jIl N 'S' m?904 Peel A1 61"t �SYSTEM PR l I m 37.25 •. ;; 4.Not to Scae 4' 4' II Effective Length 3'min. Okarance tr �trT'Y 2.5 ,, T ' mn�-,2'-min. Inlet to outlet mh GENERAL NOTES ;�3 OUTLET a L uTdTevel 8 mpa red stone 1/2' � Effective wroth * 10� ^`' 1. Contractor is responsible for Digsafe notification compacted stone s' -T I_. ;�5' -7- u m° INFILTATROR HIGH CAPACITY CH-20 LOADING)/ GEORGE O'BRIEN g and protection of all underground utilities and pipes. Bottom of Test Hole 1 Elev. ' E J ,,, -0 min. 2. The septic tonk and, distribution box shall be set j (OR EQUIVALENT) Not to Scale ; b$ level on 6" of 3/4 -1 1/2" stone. vObs. Groundwater - Test Hole 1 Elev.= NONE OBSERVED '' 3. Backfill should be clean sand or ravel with no NOTE: OVERALL HEIGHT OF INFILTRATOR 15 18" /EFFECTIVE HEIGHT IS 10" � ~� ;� g I stones over 3 in size. 4. This system is subject to inspection during installation NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6' BELOW GRADE f by Carmen E. Shay - Environmental Services, Inc. CROSS SECTION END-SECTION 5. The contractor shall install this system in accordance with Title V of the Massachusetts state code, the approved plan TYPICAL 1500 GALLON SEPTIC TANK and Local Regulations. NOT TO SCALE 6. If, during installation the contractor encounters any I (H- 10 LOADING) soil conditions or site conditions that are different from those shown on the soil log or in our design N/F Shirley Evans installation must halt & immediate notification be �1 made to Carmen E. Shay - Environmental Services, Inc. I 7. No vehicle or heavy machinery shall drive over the PERCOLATION TEST septic system unless noted as H-20 septic components. _ 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. 75 ---___ 1 1 o 9. All Distribution Lines shall be 4" diameter Sch. 40 NSF PVC pipes. 96. Date of Percolation Test: MAY 12, 2004 10. All solid piping, tees & fittings shall be 4" diameter N\ Test Performed By. CARMEN E. SHAY, R.S„ C.S.E. Schedule 40 NSF PVC pipes with water tight joints. Results Witnessed By. WAIVER per BARNSTABLE BOH Excavator: Roberts Septic Service 11. Municipal Water is Connected to ALL OF The Residence and Abutting \ Percolation Rate: Less Than 2 min./inch ® 24" BELOW GRADE. Properties Within 150 Feet. \ \ \ , NOTE: 'i Test Hole THE PROPERTY LINES ARE APPROXIMATE AND No. 1 COMPILED FROM THE ASSESSORS INFORMATION, EDWARD E. KELLEY OF OSTERVILLE, MA, DATED 4/03/85 1 / DEPTH SOILS ELEV., THE DEED DESCRIPTION AND OTHER SOURCES. I i 0 98.60j AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN 1 Loamy Sand IT SHOULD BE USED FOR NO PURPOSE OTHER THAN 10 YR 3/2 THE SEPTIC SYSTEM INSTALLATION. 0"-8" Ap 97.33 Loamy San 10 YR 5/6 I THERE ARE NO WETLANDS LOCATED WITHIN A 200' RADIUS OF THE SAS. 8 30" Bw 95.501 1 Med / 1 Sand 2.5 Y 7/4 I NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE MAP 141 PARCEL 051 30'-144" C, L22o 1 FROM THE EXISTING SEPTIC SYSTEM TO BE DISPOSED ' 33,326 Square Feet +/- It I OF AS PER BOARD OF HEALTH SPECIFICATIONS. EXISTING CESSPOOLS TO BE PUMPED DRY & FILLED IN PLACE OR REMOVED TO FACILITATE INSTALATION OF NEW SAS IF REQUIRED. N/F Raymond L. Goodspeed �(I ' 1 ASSESSORS MAP - 141 PARCEL - 051 * Per6 #1 ZONING - RESIDENTIAL I I Depth to Perc: 30" to 48" l I Perc Rate=<2 min./inch Groundwater Not Observed I BOTTOM OF TEST HOLE Elev. =a 144" 17HERE 4RE NO WETLANDS LOCATED W^THIN A 200' RADIUS OF THE SAS. 1� ADJUSTED H2O Elev. No Adjustment required. it � I O ALL OUTLET PIPES FROM THE 1 DISTRIBUTION BOX SHALL BE i L �?E SET LEVEL FOR AT LEAST 2 FT. (^ 12" �CCNCR£TE C04ER / KNOCKOUTS I 8XC ND DENO TES PROPOSED ouTLET i 12- INLET SCOT GRADE 6- e. X 104.46 DENOTES EXISTING •o> .,.,. �. 2- SPOT GRADE -------------------- ---- ----106 1s.s" iL7s PL PROPERTY LINE PLAN SECTION CROSS-SECTION PROPOSED CONTOUR N/F Hillside Cemetary cP� � l / ,. _ ,\ --- 10� 3 HOLE DISTRIBUTION BOX 97- - - - - -97 EXISTING CONTOUR o / ( i \�� I NOT TO SCALE DEEP TEST HOLE & PERCOLATION TEST LOCATION I , Design Calculations FENCE 4" PVC :r VENT PIPE Number of Bedrooms: 3 Equivalent to 330 Gal./Day (330 Gal./Day Min. per Title V) - Fdiled Garbage Grinder: No 'Asphalt �� Cesspool - ___j 00 Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) PRIVATE DRINKING WATER WELL Septic Tank : - 3 x 330 Gat./Day = 660 USE NEW 1,500 GAL. Septic Tank. \ / SOIL ABSORPTION AREA: Using percolation rate of <2 min, inch REVISIONS Driveway � �' •, •a„ 9 P /• 4 Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. = 273.8 gallons \13 . 5' ,�i'44�• ! /r 500 GALLON Sidewall Area: 0.74 gal./sq. ft. x 78 sq. ft. 58 gallons 0 Providing: = 331.80 gallons NO. DATE: DEFINITION SEPTIC TANK ' \ ' I \ •.ti' • `'' Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH �� \� ,� \\ ' ""t • �'� � '' O��' TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE ON THE ENDS. NO STONE UNDER. 10 0 I TEST HOLE #1 �'-��\ CO ELEV.= 98.00 I 1 Foiled ROPOSED O i i\\\\ \\ ', \\� HOUSE #f 02 Cesspool ;/ PREPARED FOR . \ EXISTING SUBSURFACE SEWAGE DISPOSAL SYSTEM 3 BEDROOM �,' 9 6 \\ ` HOUSE �' '' 9� OF \\ GEORGE GUSCOTT 92 # 102 OLD MILL ROAD I OSTERVI LLE MA o 102 OLD MILL_ ROAD , 10 0 PROJECT BENCH MARK ' \\ _ � � � ------ -' � ��' PREPARED BY: I TOP OF FOUNDATION . . _ - ELEV. = 100.00 (Assumed) ____ ____--'-- OSTERVILLE, MA 02655 • 9 -__�L.._--'��• .�• ,� ,.k'' � � moo`' RM ti -RHEN E. SHA .Y ,- E. ENVIRONMENTAL SER VICES, INC. 1 \GNP of �N P.O. BOX 627 EAST FALMOUTH MA 02536 r �p0� ' 0SgNITARIN TEL/FAX 508-548-0796 SCALE: 1"=20' DRAWN BY: CES DATE: MAY 18, 2004 PROJECT#SD-575 FILENAME: SD575PP.DWG SHEET 1 OF 1 r