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Home My WebLink About0420 OLD MILL ROAD - Health �. 420 Old Mill Road Osterville P. A — 166 011 , — Commonwealth of Massachusetts �® W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c^ m M 420 Old Mill Road ?D Property Address Richard Allen ' Owner Owner's Name information is Osterville MA 02655 September 6, 2016a required for every P � ► w�� 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 I way. Please see completeness checklist at the end of the form. Important:When A. General Information S� �Sa' filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. David Mason r� Company Name 4 Glacier Path Company Address r East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Z��46— U&M&oV— September 9, 2016 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-PaaggeJ11 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 420 Old Mill Road Property Address Richard Allen Owner Owner's Name information is Osterville MA 02655 September 6, 2016 required for every � page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This report represents only the condition of the system observed on September 6, 2016 at 10AM and does not represent the future operation of the system. 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ;M 420 Old Mill Road Property Address Richard Allen Owner Owner's Name information is Osterville MA 02655 September 6 2016 required for every p 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 420 Old Mill Road Property Address Richard Allen Owner Owner's Name information is Osterville MA 02655 September 6, 2016 required for every _ P page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 420 Old Mill Road Property Address Richard Allen Owner Owner's Name information is Osterville MA 02655 September 6, 2016 required for every P a e. Cityrrown State Zip Code Date of Inspection P9 P P B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 420 Old Mill Road Property Address Richard Allen Owner Owner's Name information is Osterville MA 02655 September 6, 2016 required for every P page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were an of the system components pumped out in the previous two weeks? Y Y P P P ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 420 Old Mill Road Property Address Richard Allen Owner Owner's Name information is Osterville MA 02655 September 6, 2016 required for every p page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (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 years usage(gpd)): Yes Detail: 2014; 53,000 gallons and 2015;57,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 420 Old Mill Road Property Address Richard Allen Owner Owner's Name information is Osterville MA 02655 September 6, 2016 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Board of Health 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 420 Old Mill Road Property Address Richard Allen Owner Owner's Name information is Osterville MA 02655 September 6, 2016 required for every p page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Components reprsent a sysem installed 1995 or recent Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2feet 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 Typical Sludge depth: 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 420 Old Mill Road Property Address Richard Allen Owner Owner's Name information is P required for every Osterville MA 02655 September 6, 2016 page. Cityrrown 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 36" Scum thickness 5" Distance from top of scum to top of outlet tee or baffle 3 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent level with outlet invert. Tank is 31 inches below grade. Riser is within 20 inches of grade. 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts F W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 420 Old Mill Road Property Address Richard Allen Owner Owner's Name information is Osterville MA 02655 September 6 2016 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 420 Old Mill Road Property Address Richard Allen Owner Owner's Name information is Osterville MA 02655 September 6 2016 required for every P page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Effluent level with 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.): Dbox is 30 inches below grade. No signs of solids carryover. 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.): * 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 420 Old Mill Road Property Address Richard Allen Owner Owner's Name information is Osterville MA 02655 September 6 2016 required for every p , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2-Chambers 48 inches below grade. Risers are 36 inches below grade. Chambers holding 2 inches of effluent. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 420 Old Mill Road Property Address Richard Allen Owner Owner's Name information is p required for every Osterville MA 02655 September 6, 2016 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 420 Old Mill Road Property Address Richard Allen Owner Owner's Name information is Osterville MA 02655 September 6, 2016 required for every p page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 420 Old Mill Road Property Address Richard Allen Owner Owner's Name information is p required for every Osterville MA 02655 September 6 2016 page. CitylTown 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: 18 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: Groundwater Contour Map ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain.- You must describe how you established the high ground water elevation: Groundwater Contour Map 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 GM , 420 Old Mill Road Property Address Richard Allen _ Owner Owner's Name information is p required for every Osterville MA 02655 September 6, 2016 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information— Estimated depth to high groundwater E 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 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE D ISYUSAL SYST EM M INSPECTION FARM PART C SYSTEM INFORMATION(continued) Property Addm%.42.0 Old Mill!toad Osterviile Owner:L Labella Date Of inspection: 3/1/42 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference Iandu�erlcs or benchmarks.Locate all wells within 1()0 feet.Locate where public yratet sujy caters the building- Front of Rome 3u. r ��r f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE•OF ENVIRONMENTAL AFFAIRS + a DEPARTMENT OF ENVIRONMENTAL PROTECTIONa�` h Q RECEIVED I } y0 APR 2 9 2003 TITLE S TOWN OF BARNSTABLE HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAR Property Address:420 Old Mill Road PARCEL - O Osterville Owner's Name: L.Labella LOT Owner's Address: Same Date of Inspection:3/1/03 Name of Inspector: Timothy Lovell Company Name:Accurate Septic Inspections Mailing Address:550 Willow Street West Yarmouth,MA 02673 Telephone Number: (508)—771-3700 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F 'ls Inspector's Signature 1 �� _....._� Date: 3/1/03 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30-4ys 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. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 420 Old Mill Road Osterville Owner: L.Labella Date of Inspection:3/1/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: _n/a_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. _n/a_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. ND explain: _n/a_ 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: n/a_ 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): 1 broken pipe(s)are replaced obstruction is removed ND explain: s Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ; CERTIFICATION(continued) Property Address:420 Old Mill Road Osterville Owner: L.Labella Date of Inspection:3/1/02 C. Further Evaluation is Required by.the Board of Health: _n/a Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria 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: a Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:420 Old Mill Road Osterville Owner: L.Labella Date of Inspection:3/1/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _x_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _x_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _x Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow _xT Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _x_ Any portion of the SAS,cesspool or privy is below high groundwater elevation. _ _x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. x_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _x_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _x_ 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 i9 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.] _N o (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: n/a To be considered a large system the system must 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:420 Old Mill Road Osterville Owner:L.Labella Date of Inspection: 3/1/02 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _x Pumping information was provided by the owner,occupant,or Board of Health _x Were any of the system components pumped out in the previous two weeks? _x _ Has the system received normal flows in the previous two week period? _x Have large volumes of water been introduced to the system recently or as part of this inspection? _x _ Were as built plans of the system obtained and examined?(If they were not available note as NIA) _x _ Was the facility or dwelling inspected for signs of sewage back up? _x _ Was the site inspected for signs of break out? _x _ 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? _x 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 _x _ Existing information.For example,a plan at the Board of Health. x_ 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)j Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 420 Old Mill Road Osterville Owner:L.Labella Date of Inspection:311/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_3_Number of bedrooms(actual):_3_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_330 Number of current residents: Does residence have a garbage grinder(yes or no):_no_ Is laundry on a separate sewage system(yes or no):_no_ [if yes separate inspection required] Laundry system inspected(yes or no):_n/a_ Seasonal use: (yes or no):_no_ Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):_no_ Last date of occupancy:_Current 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: None' 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 _x Septic tank,distribution box, soil absorption system _Single cesspool Overflow cesspool —ivy _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: July 101998 Were sewage odors detected when arriving at the site(yes or no):_x_ Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:420 Old Mill Road Osterville Owner: L.Labella Date of Inspection:3/1/02 BUILDING SEWER(locate on site plan) Depth below grade:_38" Materials of construction:_cast iron _x 40 PVC other(explain): Distance from private water supply well or suction line: 50' + Comments(on condition of joints,venting,evidence of leakage,etc.): No evidence of leakage,Joints look tight,Venting looks to working at time of inspection, SEPTIC TANK:_x (locate on site plan) Depth below grade:_18" Material of construction:_x_concrete_metal_fiberglass_polyethylene_other (explain) If tank is metal list age:_Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 1500 Gallon Tank Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:_301, Scum thickness:_0" Distance from top of scum to top of outlet tee or baffle:_6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: 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.): Recommend pumping septic tank evea 2 years for proper maintenance, Structurally sound,liquid levels at invert out,no evidence of leakage GREASE TRAP:_n/a (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.): I Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:420 Old Mill Road Osterville Owner: L.Labella Date of Inspection: 3/1/02 TIGHT or HOLDING TANK:_n/a_(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of constructiom concrete metal fiberglass_polyethylene other(explam): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_z (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.): Cover 35" deep,oversize D Box H-20 loading liquid levels at invert out,no solid carry over, no evidence of leakage PUMP CHAMBER:_n/a (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 420 Old Mill Road Osterville Owner: L.Labella Date of Inspection:3/1/02 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ _x_leaching chambers,number: 2_ leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): 2-500 gallon chambers,in a 13x25 trench,2'deep,no ponding,vegetation normal,no evidence of hydraulic failure at time of inspection CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: " Depth of solids layer: , Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,- level of ponding,condition of vegetation,etc.): PRIVY:_n/a_(locate on site plan) Materials of construction: Dimensions: _ Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 420 Old Mill Road Osterville Owner: L.Labella Date of Inspection:3/1/02 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. Front of Home I a �o. I 1 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 420 Old Mill Road Osterville Owner:Labella Date of Inspection:3/1/03 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 35'_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: Checked w,tll.local.excavators installers-(attach documentation). X_Accessed USGS'database-explain:_Plate2 You must describe how you established the high ground water elevation: Information provided by Cape Cod Commission,ar, opo Zone.com`Vell# :'2 '' Approx.topoof d 'VPS 9 .�J: is. � property is 45.0 bottom of SAS is aprox. 39.0 which is a 30' seperation TopoZone - The Web's Topographic Map Page 1 of 2 ann A 0 Target is UTM 19 385220E 460979ON - COTUIT quad [Quad Infol North ti��,Iopozone.00m ;. GUYIyht 2000 M etis u IBA etfE,lttr r / 1 e+ Y �l i'`, ► �3� � sal`: l •f f." '` .� -_.tee .•riYr 9 t l,_ •! r•: Y -Y j u •a� ya w� iA�Q�y ! tlo �' �i#x /sue r;' a +� r, i., ij ', _, •� • • .. �.: '!�� .-qr F t� i,.. __`tom L 7{ `'C`*�fl�er�, t {'c71v a � u 1-3' i �•p• :� t ( !': Z �' 1 -B'' i"W ,p(�•� /J ! i� W y _ 1✓1�.,. �' -:\ v� �--�'1 � 'i t,�''+S,r t 1 �` - s�...� �!;! .�d )< b/� t,. i✓ r... `'" �{P(��7~r 31`X p .a t t �! �3�� •n�i R�``� ��f, _ 3 s"'RRR '('„7 l • •-— +l Cs�'� J,�jjV L ... � • ate, R 0 ` x f�•rX. tit _ ♦�+ 4�. 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PIP hit • � � _ { fp s..t_\ {1� s •.ice • ♦•�y • • ,• •it ,: �1 ee21C', •,` o • •! •,t i , tl ja L �<parker Neck �, :+ ► a,:-- ° .► '. • • y 40) ;,ra_ � a i 0 500 1000 1500 2000 meters i i R i miles i 0.5 1 http://c,,w,,v.topozone.comlprint.asp?z=19&n=4609"190&e=385220&s=25 3/8/03 JAN-02-2003 THU 01 : 16 PH REALTY EXECUTIVES 508 362 1313 P, 02 Dtho Ea OP 10101a (508)770-55!36 MAMA P.2 P ••« •••• .rry aavwv J3 JUF//yW7L?Y1 ®1 f Ar. CERTUUD PLOT PLAN „ c=w" Tur LOT i OLD ��tov�w ON TM nAM IStOT14 AM ON c♦arr�os MAT IT �> �® ClD PMCFAM poi e CIUNNEL FOWT REALTY TRUST SCAM WAY 14.19ft ��11lt& Qua l� iiN ��O.g�',att�#��gyp,.d� �• �::�< 'V V O TOWN OF BARNSTABLE /01,// Ad- SEWAGE # VILLAGE ASSESSOR'S MAP & LOT / i's/Cko(,. ,J r H4STAL-L-ER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ` Soy`� //dam � i� '(size) 2 NO. OF BEDROOMS BUILDER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 3O Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by !! 4 a 9� \� �. ` � '\" r` �� °�� 3c� /6. G t C TOWN OF BARNSTABLE IV--F 1&4° @ to.e oO 1.. 41-00 LO&A-i N 1 ,2Q Dl-rD�LL l: goSEWAGE# GI a 12 g- i�6-oI/-t►o2 VII.LAGE OS trg y iLL� ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. B C R 27 8-o 4 �f- SEPTIC TANK CAPACITY 1 Sa o c sT LEACHING FACILITY: (type) ®o 'S4L mR YwGLL5- (size) 1 3 'x ZS x Zr NO.OF BEDROOMS BUILDER OR OWNER C HA,)a j C-4 401 T k Lt y `T c PERMIT DATE: _ 4� .'Y , q SI COMPLIANCE DATE: —(0 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet PrivatgWater Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Li — cl . y No. �U '�Z ( Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Miopooal *proem Con!6truction Permit Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. 4-do Owner's Name,Address and t Assessor's Map/Parcel �m�� 26 .� Installer's Name,Address,and el.N Designer's Name,Address and Tel.No. t � /,// Type of Building: r'- Dwelling No.of Bedrooms y Lot Size `� �°ssq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 gallons per day. Calculated daily flow :3 5-3 gallons. Plan Date Number of sheets 11 Revision Date Title Size of Septic Tank / S'(j� 5'r,/ Type of S.A.S. `L"3-09 C40_,gl-4.f Description of Soil 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 provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has bejised bythis Board of Heal . Signe ° Date Application Approved by Date r Application Disapproved for the following reasons Permit No. / Date Issued ^ -. � .o+..r^.y-...M,.r.l.+..+� ..F::sa...N!'"Xn.w,.M¢..r-..... ...,.....` ..,-....•....,."r......... . .... .- -.. - .. -r: -.�,a,._-,.,..,-.-.rar..�-..P.u!'� No. /!J — l Z— �k* Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for �Dioogar *p-5tem (fon.mruction permit Application for a Permit to Construct(t.4epair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. L D?' L Owner's Name,Address and o. t OSAWV 4- /`G Qom{t Assessor's Map/Parcel ,(� � O SAC 26 1 Installer's Name,Address,and Tel.)4 Designer's Nam ,Address and vz& Tel No. .1941cwc� � � Type of Building: z r- Dwelling No.of Bedrooms Lot Size , y "sq.ft. Garbage Grinder`( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow r'S 3 gallons per day. Calculated daily,flow S 3 gallons. Plan Date C-g Number of sheets Revision Date Title Size of Septic Tank �"0 o a�. Type of S.A.S. 3-4'd 9 CA a. Description of Soils SGO� t H.� it 31 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: y 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 is ed by�this Board of Heal , Signed v; Date Application Approved by Date Application Disapproved for the following reasons Permit No. 2 l T- Date Issued - 7 ————— ———————————————— ' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( Repaired( )Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 91--Z dated 7--114 Installer Designer The issuance of this permit shall not e�f nstrued as a guarantee that the cyst m will function as designed. Date 7 1 ,0 � D Inspector - —--- ^7------------------------ `' j ------ No. Fee ' THE COMMONWEALTH OF MASSACHUSETTS , PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS mi.5pozar 6 "tens Construction Permit , Permission is hereby granted to Construct( Repair( pgrade( )Abandon( _ ) System located at 41 7i D 9/r/ �f',;// aW 0 Q 5 ..1-,Z& and as described in the above Application for Disposal System.Construction"Permit.The,applicant recognizes his 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: Approved by ` - i 1 - 30 - BTa 3 n S TOWN OF BARNSTABLE ' 1 0 r 1. cep �.. LOCATION OL-0 ` uAi LL R D SEWAGE # 12 VILLAGE OS r-r e u i'LLg- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 8 C 717 y 1�if- SEPTIC TANK CAPACITY So y c sT LEACHING FACMI TY: (type) 'S 4L 0.e Y.j 9LLs" (size) 1 R 'x ZI-x Z� NO.OF BEDROOMS BUILDER OR OWNER C 11,4 40i-*VT R Zt y Tie PERMTTDATE:_� -7 - Y L COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility. Feet Private Water Supply Well and Leaching Facility (If any wells exist 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 i • �� ,�DjIT,IO�I �ZU OLD. MJLL �D -A All APPROVED BY: SCALE:Gpt.O�� Y-4 DRAWN BY GL„A�!j�Q.. DATE:'. JET _ t DRAWING NUMBER M �iZO OLD ��L .�• .r LEJ O •L . s , My SCALE:��Q s //� APPROVED BY: DRAWN BY GGv�/Q DATE: DRAWING NUMBER 4AA4Gtz: ADD i 7Ti0�/ Mo4- SCALE: /-0� /�i APPROVED BY: DRAWN BY (J�►d DATE: ieti�XlK DRAWING NUMBER 7Z ^I SCALE: /-Q 7-1V14 APPROVED BY: DRAWN BY'!j DATE: �'�! DRAWING NUMBER ��GT ion/ a 8'"YfiK GvMG. WQzz to i I. I41 Li PAO> MA // lO! 4A 6" I/�U <� SCALE: �� /,1/ APPROVED BY: DRAWN BY DATE DRAWING NUMBER • 22e-O"� 8+_fix w , O I "`� y • . �f20 oL•1y N1/LL �j. Lh i SCALE: ��b APPROVED BY: DRAWN BY GNt(JD�O DATE: DRAWING NUMBER • � 2X/2 R%D6�E rZo� FL-rip Y 4 axe 7�XFTF-lZ O �Xl2. 72iDya:. : t - �T09A K g LVLM" 2x A - jt�57"«ICE i PW �NG� 4 *7`09 Co-NIC-FACM ` scam. gwa A A20 OL,P MILL P->. rHK A?>Pi 057aeViG� , MA *ova.AA io/V wAU- rFH SCALE:.� y/. 'APPROVED BY: DRAWN BY GL�4v.�IO !'X Sa�T�1l�c DATE: 00 '�OfTfiN(� DRAWING NUMBER I �iTAni�i UYF-Nlnl�r - I M ' 00 yx 2x8 bfAA4 LJLJ -- - 47-o 06P MrLL xo. MA SCALE: I-o i � APPROVED BY: DRAWN BY GLiQlJ,A►G s DATE: 4_567 2006 DRAWING NUMBER 420 0/ap� /yiLL •T Ia . �D r' SCALE: /�O^ APPROVED BY: DRAWN BY �A'D • DATE: 1 2 . DRAWING NUMBER i o ,y N TEST HOLE LOG DATE: FEc4, SOIL EVALUATOR WITNESS: -. 4 PERC RATE: -c- Z y ti O .3 3 E GoANY a� I 32� /a Y� s/� .S•qw o C/,v '1 Lam. a°NZ [ow.0 y' 8W2 toAw/y ,1 1 S.qA/p o �-- -- z SY�Z o 4 z,s z ' 1+ Sg jg4d le �y DESIGN DATA z 85 � �� J y V � 0 DAILY FLOW:(3)BDRMS.z 110-GPD= 33o GPD SEPTIC TANK: 33o GPD z 200%= 6,40 GPD USE./So a GALLON PRECAST SEPTIC TANK v LEACHING FACILITY: USE: :5!-'><8.5-'xZ_�� Soo CT O wEccS CAPACITY: �- SEDEWALL:-..7(-- z x o,7 v BOTTOM:' /3.r zs xo.7� = Z5�•S _ ��y`tR os TOTAL: -3 53. ILM p se Aj ` F C✓1 ' OF MAss9 4, -cam O DANIEI L CyG BRAMAN N NOTES: -v CIVIL , v 1. ALL PIPE TO BE 4"DIA.SCH 40 PVC. ci No.32666C 2. PIPE TO BE LAID LEVEL FOR 2'OUT OF DISTRIBUTION BOX. pG15T��` 3. RAISE ALL APPLICABLE MANHOLE COVERS TO WITHIN 0 P� O" CQ G U S 6"OF FINISH GRADE G 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL. I - g 5. SEPTIC TANK AND DISTRIBUTION BOX TO BE INSTALLED ON A 6"LAYER OF STONE 6. INSTALL GAS BAFFLE IN OUTLET TEL 2•LAYER OF 3B•PEASTONE OVER 3/4*-1 V2•WAMD STONE ALL AROUND TOP OF FOUND. Ell. �p/.oa/ 10, u• \ 32 .5/z o • .< . S.�zS SS.oa Syoo • SEPTIC SYSTEM PROFILE ;a z�wE is .uaTj.t� .q•J L G�.vc�•..� SITE SEWAGE PLAN GENERAL NOTES • 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION FOR • OF ALL UTILITIES,ABOVE AND UNDERGROUND,PRIOR G�� M�G G �•/ Q��v/G L� TO ANY EXCAVATION OR CONSTRUCTION. /�G Z ylo8/�O�r/li 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH PREPARED FOR �Io ISM oo:TITLE v. 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE DETERMINATION. 4 4. ALL DISTURBED AREAS TO LOAMED AND SEEDER DATE: �j�.� Gf /;�5iM SCALE: / _�ca' S. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY REQUIRED INSPECTIONS. G- C F/9Ch�/NE7 .9C/C./T� S .�E/UGf►i G C..w/_T/�-_._ CL E A ti S.A nJ7�.• / ' WELLER & ASSOCIATES . 1645 FALMOUTH ROAD CENTERVILLE, MA. 02632 TEL: (508)775-0735 FAX: (508)775-0754 APPROVED BY: