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HomeMy WebLinkAbout0025 OLD SALEM WAY - Health E1( Sa,.Iem. �Wayille' 6 -0616 I t Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 25 Old Salem Way ' Property Address Pal Mike Rosenfelt :, Owner Owner's Name WJ information is required for every Osterville Ma. 02655 06-19-2018 '1 page. City/Town State Zip Code Date of Inspection ;,.4 INO 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 coml use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections Company Name 624 Old Barnstable Road Company Address rem Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 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 P 06-21-2018 Inspector's Ignature 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 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form �) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Old Salem Way Property Address Mike Rosenfelt Owner Owner's Name information is required for every Osterville Ma. 02655 06-19-2018 page. CityTrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 3 bedroom home has a H-10 1000 gallon septic tank and a H-10 D-Box with two leaching pits. At the time of the inspection there were no visible signs of past hydraulic failure in one of the leaching pits. 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Old Salem Way Property Address Mike Rosenfelt Owner Owner's Name information is required for everyOsterville Ma. 02655 06-19-2018 page. Cityfrown 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - F Tit le e 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M 25 Old Salem Way Property Address Mike Rosenfelt Owner Owner's Name information is required for every Osterville Ma. 02655 06-19-2018 page. Citylrown 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 0 ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 25 Old Salem Way Property Address Mike Rosenfelt Owner Owner's Name information is required for every Osterville Ma. 02655 06-19-2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. 0 ® 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. E ® 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 25 Old Salem Way Property Address Mike Rosenfelt Owner Owner's Name information is required for every Osterville Ma. 02655 06-19-2018 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD t5ins.doc•rev.6/16 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 25 Old Salem Way Property Address p Y Mike Rosenfelt Owner Owner's Name information is required for every Osterville Ma. 02655 06-19-2018 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)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 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 25 Old Salem Way Property Address Mike Rosenfelt Owner Owner's Name information is required for every Osterville Ma. 02655 06-19-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 4 M , 25 Old Salem Way Property Address Mike Rosenfelt Owner Owner's Name information is required for every Osterville Ma. 02655 06-19-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: New leaching pit installed in 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 29"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years i Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Standard H-10 1000 gallon septic tank 1 Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 25 Old Salem Way Property Address Mike Rosenfelt Owner Owner's Name information is required for every Osterville Ma. 02655 06-19-2018 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" 1 Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The Barnstable Health Dept. has a list of local septic pumping co. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M . 25 Old Salem Way Property Address Mike Rosenfelt Owner Owner's Name information is required for every Osterville Ma. 02655 06-19-2018 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: 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.doc•rev.6/16 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 G M , 25 Old Salem Way Property Address Mike Rosenfelt Owner Owner's Name information is required for every Osterville Ma. 02655 06-19-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The H-10 D-Box had no visible signs of leakage or evidence of past hydraulic failure. 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: I t5ins.doc-rev.6/16 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 M 25 Old Salem Way Property Address Mike Rosenfelt Owner Owner's Name information is required for every Osterville Ma. 02655 06-19-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): At the time of the inspection there were no visible signs of past hydraulic failure in the newer leaching pit. 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 25 Old Salem Way Property Address Mike Rosenfelt Owner Owner's Name information is required for every Osterville Ma. 02655 06-19-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Ili t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Old Salem Way Property Address Mike Rosenfelt Owner Owner's Name information is required for every Osterville Ma. 02655 06-19-2018 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 fif- bar` 00,j i t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 I TOWN OF BARNSTABLE p LOCATIONS n4/7 SALeve L,A _SF WAGE # VILLAGE D SrfR✓1 L/ 6 ASSESSOR'S. MAP 6 LOT INSTALLER'S NAME& PHONE NO. J /� /0.4C QAn 0 X. r Sd i/ SEPTIC TANK CAPACITY_ /Qpa LEACHING FACILITY-(type).✓pai 1 i7' (size) /.d o d NO.OF BEDROOMS .3 PRIVATE WELL OR PUBLIC WATER WWOER OR OWNER DATE PERMIT ISSUED:__ DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No G- i i 0 Commonwealth of Massachusetts w W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 25 Old Salem Way Property Address Mike Rosenfelt Owner Owner's Name information is required for every Osterville Ma. 02655 06-19-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 14 plus feet 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: 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: I augered a hole to fourteen feet to show four plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 25 Old Salem Way Property Address Mike Rosenfelt Owner Owner's Name information is required for every Osterville Ma. 02655 06-19-2018 page. Cityfrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE 4 k---` LOCATION � n /7 S L ems+ Lac SEWAGE # VILLAGE 0-57�� V1141- e ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. J Q 1VI 0 e 1r. f- S d U SEPTIC TANK CAPACITY LEACHING FACILITY:(type)i✓eed (size) /d o 0- NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER 5&4EMR OR OWNER d ,o ��/i v DATE PERMIT ISSUED: g DATE COMPLIANCE ISSUED: ell VARIANCE GRANTED: Yes No �- ,� t �` ��''' � i � `�\ � � aY`. I �, � � �Q 0 - _� :a-CN Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'Y< 25 Old Salem Way Property Address William Marth Owner Owners Name information is requireti'for every Osterville MA 02655 7-30-13 page. Cityrrown 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 ,,,,,,,,tttl on the computer, \'�-¢ 8� ` ��� (N OF ',44 .. use only the tab key to move your 1. Inspector: -� �� .•••.. cursor-do not James D.Sears = JA M E S '-cps use the return key. Name a e of Inspector ,* •� Capewide Enterprises, LLC �V Company Name 153 Commercial$t. 0j �5 INSPt���`````\ Company Address Mashpee MA 02649 C' !Town ►hr State Zip Code 508-477-8877 S1623 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. 1 am a DER approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority )21ae),� 7-30-13 peaoes 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 shalt 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•3M 3 Title 5 Olfidal bspeaion F Sewage Disposal Systern•Page 1 of 17 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Old Salem Way Property Address William Marth Owner Owners Name information is required for every Osterville MA 02655 7-30-13 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: 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 exfiftration 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): I i t5ins•3M3 Title 5 ofrtdal won Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth_of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 25 Old Salem Way Property Address William Marth Owner Owner's Name information is required for every Osterville MA 02655 7-30-13 . page. CityfTown 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): 1 ❑ 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): s 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 CHAR 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•3113 Title 5 Official ins pection Farm;Subsurface Selvage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ~ 25 Old Salem Way Property Address William Marth Owner owner's Name information is required for every Osterville MA 02665 7-30-13 page. Cityfrown 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#II 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•3M 3 Title 5 Official inspection Form:Subsurfece Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts WWTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Old Salem Way Property Address William Marth Owner owner's Name information is Osterville MA 02655 7-30-13 required for every page. Cityrrowm State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official kwectlon Form:Subs<xface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts z VTitle 5 Official Inspection Form t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 50 25 Old Salem Way Property Address William Marth Owner Owner's Name information is required for every Osterville MA 02655 7-30-13 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 i❑ s 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 offioal Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts ms,mljTitle 5 Official Inspection Form WSubsurface Sewage Disposal System Form-Not for Voluntary Assessments O 25 Old Salem Way Property Address William Marth Owner Owner's) � Oer Oers Name information is required for every Osterville MA 02655 7-30-13 page. cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal.Tank D. Box and two pits. Number of current residents: 4 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 2011-36,000Gais g ( y g (gp ))' 2012-40,000 Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Tithe 5 Official Inspection Form:Subsurface Sewage Disposal System-Pap 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Old Salem Way Property Address William Marth Owner Owner's Name Information is required for every Osterville MA 02655 7-30-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 05/06/08/10 Capewide 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/Altemative 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 We 5 Official Inspection Forth:Stbsurface Sewage Disposal System-Page 8 of 17 I Commonwealth of Massachusetts Wo Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Old Salem Way Property Address William Marth Owner Owner's Name information is required for every Osterville MA 02655 7-30-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed(if known)and source of information: New Pit instaled 1994-Permit# 94-709/New D Box 7-13 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 32"feet Material of construction: ❑cast iron ®40 PVC ®other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4"PVC SCH 40&SCH 20. Septic Tank(locate on site plan): Depth below grade: 20"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast Sludge depth: 2° t5ins•W13 Title 5 official Inspection Forth: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 25 Old Salem Way Property Address William Marth Owner Owner's Name information is required for every Osterville MA 02655 7-30-13 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 28" 1" Scum thickness Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 1711 How were dimensions determined? Asbuilt-TapeSludge Judge 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 at working level. Tank and outlet cover at 20"below grade,w/inlet cover at 4". Inlet baffle two outlets, Baffle and tee. Outlet tee lower then baffle. No sign of leakage or over loading. Note: Tank to be Maint pumped afther Inspection Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene 'El other(explain): Dimensions: Scum thickness Distance from.top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3H 3 Title 5 Official Inspection Form:SWsuRace Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Old Salem Way Property Address William Marth Owner Owner's Name information is required for every Osterville MA 02665 7-30-13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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 ction Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i� 25 Old Salem Way Property Address William Marth Owner Owner's Name information is required for everyOsterville MA 02655 7-30-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 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.): D Box is new 7-13. D Box is 16"x16"-30" Below grade w/cover at 6'. One tine out 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•3/13 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W09 Title 5 Official Inspection Form C Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w" 25 Old Salem Way Property Address William Marth Owner Owner's Name information is required for every Osterville MA 02655 7-30-13 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: 13 leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system T e/name of technology: 9Y: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two precast pits. Older pit is dry. Newer pit is a 6'deep H-20 Precast. Pit at 20"below grade w/2'water. No sign of over loading or solid cant'over. No higher stain line. 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-3M 3 Title 5 Offroal fnspec ion Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Old Salem Way Property Address William Marth Owner Owner's Name information is required for everyOsterville MA 02655 7-30-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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 Tide 6 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 � Commonwealth of Massachusetts Law Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Old Salem Way Property Address William Marth Owner Owner's Name information es required for everyOsterville MA 02655 7-30-13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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 ❑ 9 p Y /s' R EAR Ic /9 a o 13 y 3 7' t5irts•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposes System•Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 25 Old Salem Way Property Address William Marth Owner Owner's Name information is required for every Osterville MA 02655 7-30-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope Surface water ❑ Check cellar ❑ Shallow wells N° 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: 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: Hand auger 12' no G.W.. Bottom of pit at 8'. Auger hole at 4' below bottom of pit. 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 Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Old Salem Way Property Address William Marth Owner Owner's Name information is required for every Osterville MA 02655 7-30-13 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary:A, B, C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3l13 Title 5 Official I rrspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. CIO— Fee ,6o THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Disposal �&pstrm Construction Prrmit Application for a Permit to Construct( ) Repair()� Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. J,5 ©Q,a cSALLvGt BAN Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ( ig, p 1JL1 VIA PALACi Q P GADP& -FL' Installer's Name,Address,and Tel.No. 50 �5�3�"7 Designer's Name,Address,and Tel.No. Cokvewmc, WS&-S L M&av Gag. Type of Building: CC Dwelling No.of Bedrooms Lot Size • 2"J sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Qac RgVtkC4RIA49jT 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 Certificate of Compliance has been issued by this Board of Health. Signe Date Application Approved by Date Z y Application Disapproved by Date for the following reasons Permit No.� 2� Date Issued Na. �5 Fee Entered in computer: VYel THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Bisposal *pstrm Construction permit Application for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( ) ❑Complete System EKIndividual Components Location Address or Lot No. ,15 01 0 64umw k,)Ay Owner's Name,Address,and Tel.No. p5'rtwlugo wit..4,1404 +JVn1TN MARTH s Assessor'sMap/Parcel & 12% VIA P LAO- 2 IALC btNICA &4S FL- Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. C AVEWMG KISSS L M 4Scwv ' Type of Building: Dwelling No.of Bedrooms Lot Size 2-5 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Natuire of Repairs or Alterations(Answer when applicable) B oy- ig P th(Ct $4GL) t'" x r Date last inspecteft Agreement: i 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 Certificate of Compliance has been issued by this Board of Health. Sign, Date Application Approved by Date ?jv Application Disapproved by Date for the following reasons Permit No. a25 Date Issued (� / --------------------------------------------------------------------------------------------------------------------------------------- /I THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( ) Abandoned( )by�( ;A(>C7,e.A D9 ' „PI-196-5 LL, at-:�A- ()L4) :S*L,4 g Ig _C)5"r. has been constructed in accord P�jca- with the provisions of Title 5 and the for Disposal System Construction Permit No. �r 7at�d Installer Cf►tP} (;QE �� LLC- Designer #bedrooms Approved design flow _ i gpd The issuance of this permit shall not be construed as a guarantee that the system wil fuhct�i+on-as d1esigneJd. . Date_ f Inspector / ,1 + � / No. --1/�� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *psteta Construction Vermit Permission is hereby granted to Construct( ) Repair(X) Upgrade( ) Abandon( ) System located at s+?� .Z IAIAA f 0S UILb5 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be com leted within three years of the date of thi permit. Date 7 / Approve r . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM 25 Old Salem Way Property Address Joseph Monteforte Owner Owner's Name information is required for Osterville Ma. 02655 3/28/2007 every 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 v way. Important:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name P.O.Box 763 Company Address Centerville Ma. 02632. 'e°O0 City/Town State Zip Code (508)428-4028 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 SectioiO5.34Q,of Title 5 (310 CMR 15.000). The system: j ® Passes ❑ Conditionally Passes ❑ Is , ❑ Needs Further Evaluation by the Local Approving Authority ` : 3/28/2007 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. r • 25 old salem way•08/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Old Salem Way 4„M I Property Address Joseph Monteforte Owner Owner's Name information is required for Osterville Ma. 02655 3/28/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D. A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time.Leaching pits were dry 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. 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. 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 25 old salem way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 25 Old Salem Way Property Address Joseph Monteforte Owner Owner's Name information is required for Osterville Ma. 02655 3/28/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: _ ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: 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 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. 25 old salem way•08/05 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 25 Old Salem Way Property Address Joseph Monteforte Owner Owner's Name information is required for Osterville Ma. 02655 3/28/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ 2 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® 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. 25 old salem way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Old Salem Way _ Property Address Joseph Monteforte Owner Owner's Name information is required for Osterville Ma. 02655 3/28/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 ❑ 0 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. 25 old salem way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G 25 Old Salem Way - Property Address Joseph Monteforte Owner Owner's Name information is required for Osterville Ma. 02655 3/28/2007 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must.indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? 0 ® 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. ® 0 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)] 25 old Salem way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 25 Old Salem Way Property Address Joseph Monteforte Owner Owner's Name information is required for Osterville Ma. 02655 3/28/2007 every page. City/Town State Zip Code Date of Inspection 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 Number of current residents: unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2006:61,000 g ( y g (gpd)): 2006:46,000 Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 25 old salem way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 25 Old Salem Way Property Address Joseph Monteforte Owner Owner's Name information is required for Osterville Ma. 02655 3/28/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: J.P.Macomber 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: New leaching pit installed in 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No 25 old salem way•08/66 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 25 Old Salem Way Property Address Joseph Monteforte Owner Owner's Name information is required for Osterville Ma. 02655 3/28/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i_ Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 2 feet , Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): r 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No --------------------------------------------------------------------------------------------------------------------------- Dimensions: 8'6"x4'1 0"x57' Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness none Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured 25 old salem way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 25 Old Salem Way Property Address Joseph Monteforte Owner Owner's Name information is required for Osterville Ma. 02655 3/28/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments ('on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every 2-3 years.lnlet and outlet tees are in place.Tank appears structurally sound.No evidence of leakage. Grease Trap (locate at on site plan): n s Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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) 25 old salem way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 25 Old Salem Way Property Address Joseph Monteforte Owner Owner's Name information is required for Osterville Ma. 02655 3/28/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is level and has two laterals with equal distribution.No evidence of solids carryover.No signs of leakage into or out of box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 25 old salem way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts - : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 25 Old Salem Way Property Address Joseph Monteforte Owner Owner's Name information is required for Osterville Ma. 02655 3/28/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ 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.): Sandy soil.No signs of hydraulic failure.Leaching pits were dry at time of inspection. 25 old salem way-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 25 Old Salem Way Property Address Joseph Monteforte Owner Owner's Name information is required for Osteryllle Ma. 02655 3/28/2007 . every page. City/Town State Zip Code Date of Inspection D. System Information.(cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site pllan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of 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.): ti 25 old salem way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 a. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Old Salem Way Property Address Joseph Monteforte Owner Owner's Name information is required for Osterville Ma. 02655 3/28/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. -------------- d 25 old salem way•08/06 Title 5 Official Inspection For Subsurface Sewage Disposal System•Page 14 of 14 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 25 Old Salem Way Property Address Joseph Monteforte Owner Owner's Name information is required for Osterville Ma. 02655 3/28/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to ground water: 40' 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: as-built card ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used:Gaherty& Miller model 12/16/94 ground water elevations.Used:USGS observation well data June 1992.Used:Technical bulletin 92-000-01 plate#2 annual ranges of ground water elevations. 25 old salem way•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 0. 0 0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE L',Zx Ap.pliration for Ui_v-,poottl Works Tonotrnrtion Permit Application is hereby made for a Permit to Construct ( ) or RepairX(XX) an Individual Sewage Disposal System at: .............!7oseph Po M6nteforte -------....-•------.... Location-Address or Lot No. .............:K5...Old.._Salem___Way__OstervilleoMass ................................................................................................ Owner Address W I,TAa.m cSJmb.Qr•••Jr4•----•--------••--•-------------------- Installer Address Type of Building Size Lot............................Sq. feet He Dwelling X—No. of Bedrooms.-..-.---.3...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons------------_-----_-.----- Showers ( ) — Cafeteria ( ) A4Other 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. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit........-.--.-.-.._. Depth to ground water...................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---..................... 04 ------•---------------------•----•---------•------•-------------------••-•--------------••----------.....................................................*­ 0 Description of Soil.......................................................................................................................---------------------------.................... x9�►��?----&---Gra -v yel----------------------------------------------------------------------•---------------•---------------•--------------------------••------------------ W -----------------------------------=------------------------------------------ --------•---------•----------------- -----------------------------------••------------•-----•-•---•------- %. ...... .. U Nature of Repairs or-Alterations—Answer when applicable...Ac c3: nc�_.-c�f___1.000 gallon 1ea.C7t p� ..............to...`X stinq---tank--.&.... t.'-•---••••........--•------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli nce ha bin is ued by e board of health. Signe //� Date Application Approved By ................ .............. --- ..�..G..-.g'..y Date Application Disapproved for the ollowing reasons: -------------------------------------------------------------------------------------------------------------------- ..................................................................... i 9 - -----'-----...7.7....... PermitNo. --------J. .......70f---------------------------- Issued .----------------------- ....................................... Date Flm$.5.....MAD.... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE L �Z Alip iratiun for Diuvwml Workii Tunutrnrtiun trrutit Application is hereby made for a Permit to Construct ( ) or RepairX(XX) an Individual Sewage Disposal System at: Joseph P. Mpnteforte • .................._........................................................................ .............----•••----•••-------------------------------•---••------...------........----___.. Location-Address ..........?5_• 01d.•Salem. Way--.Osterville,Mass................................................................................................ or Lot N°' Owner Address a -- ..._....J_.k.Macomher---Jr-------••--•----•--------------••----••--- -------------------------- Installer Address UType of Building Size Lot............................Sq. feet Dwelling No. of Bedrooms---_-____.3_------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 0 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. ft. 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........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................... rx -----------------------------------•----•-------------------------•-------------•----------•.._..._... 0 Description of Soil.................. U Sand & Gravel . • . --------•----•-•-•-•-----------•--•----...-•-----••-•-•-••-•--•----------•--•••---•----••-----•------•-•-••--------•-•-••••-••--------•••----•-------- W ------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------=--- M. Nature of Repairs or-Alterations—Answer when applicable-_A dina of 1 000 crallon leach PW to existing tank & tit. -- - ----------------------------------------------------------••-------......... Agreement: The undersigned agrees to install the'aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha bb�n issued by he board of health. Signed'... ...-:_::..!.W---------------�-- �:;. _1.2.--5�-9 4.. .._. Application Approved By .. - - -- --------------------------------------------�------------------ .)� � G -..C1'..�/ `" . Da[e Application Disapproved for the following reasons: ---------------------------------------------- -------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------ ��- Dare PermitNo. ........ v. 7Q7----. --------------------------- Issued .......................................................... ------ r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TlO��WN OF BARNSTABLE Qxrtifirate of (11.1IImplianre TEFIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX) by J.P.Macomber Jr. ------------------------------------------------------ ------------------------------------------------------------------------------------ -------------------------------------------------------------------------------- Insraller 25 Old Salem fila ' Osterville at ..................... ............_.............. ............_......------- --- -- ....r.l`las s/ . has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ------- ..y.-_._.T/2_ ... dated -----------------------_------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...,�� -....���.�... .. - -- - Inspector -V---- ..... - - -- --------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH p� TOWN OF BARNSTABLE 3fl Oo _ FEE.._......--•---......... Diupuual Worb Tunotrudion "pamit Permission is hereby granted.......J.P.Macomber Jr. .•---•.............. to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at No....2.5 O1d...Salem--•t4ay___Osterville•RMass.._---,_______________________________ Street as shown on the application for Disposal Works Construction Permit No�-_I�_T-.��. ___ Dated____.���_-�_'.�(7- I - -------•----•-•--•--•------.....- j ---------•-------------------------•----•---------- _ �j L� V Board of Health DATEd ........... ..l....... FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS NO--2,_-P THE COMMONWEALTH OF MASSACHUSETTS BOARD F f H EA T ... ..........OF.......... ........ ._. . .. . Appliru$iun for Mipuua1 Works Tonstrnrtiun Pumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual ewage Disposal System .. ----•--•-•-----.•-_. ion-Ad ss wner � �Address Installer ` Address d Type of Build)'n Size Lot.-Im___ �S______Sq. feet Dwellingf. No. of Bedrooms..........,.......................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type' of Building ...:........................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ................................................................................................................ Design Flow_:....................... lions per person per day. Total dailyflow.............. � gallons. WSeptic Tank—Liquid capacity __, .. allons Length................ Width-----------------Diameter-_--___--___. Depth_.__--___---_--- x Disposal Trench.No..................... Width_-.. _ Total Length......... ....:._ Total leaching area.____;___.__.._____.sq. ft. Seepage Pit No.... Diameter� De Depth below inlet____._. Total leaching area.. � es ft. - ---- P g 3----- q• Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by ---------------- Date Test Pit No. 1_..mutes per inch Depth of Test Pit.................... Depth to ground water.--__-_-_-_----___-_--. f� Test Pit No. 2------_-••--_---minutes per inch Depth of Test Pit.................... Depth to ground water--__--_.-_-___-_____---- a - --------- O Description of Soil------------- , - - - - W x -----------------------••••••-•••-••••••••-•••••••••---•••----••......•---------------............................................................ U, Nature of Repairs or Alterations—Answer when applicable._______--------_------------------------------------------------------------.-----------___.... ---------------------•----------------------....-•------••._.....•••-•--•-•-------•-••••-••---..--••-•••••••---•...---------•-••---••-•••-------•-•------------•------------------------.--•---•------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ` Sign D e Application Approved By..... •• -- • •• _ . -= /� r•-,-••••--•--••-•-- - y. f Application Disapproved for the following reasons:._____________________ _______________________R_�_____.__.______ ................... Date ............• ft- ----------------------------------------- ----------------------•--•••••......•••--•.... - - -------- Date PermitNo.......................................................... Date .4------- FEE i!!.'.`..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEIA-d-TH OF............Q... -- - -- -------- Aliptiration for Eliavoiial Workii Ton drurtion Permit A p lication is hereby made for a Permit to Construct or Repair an jndividua Sewage Disposal SL s t .... ...... ....... X............ .0...... .... --- --- ...................... n-A r ss or Lbt N' ,;; ------- .. ....... ............. .. .............................................. 0 ............------- ...... . ....j Owner Address ------------------*------------ -------------------------------------------------------------------------------------------------- Installer Address /,� f, /-,�-�' Type of Buil Size Lot----- ------------Sq. feet U Dwellinjr—No. of Bedrooms_-_____-_:z---`�----------------------Expansion Attic Garbage Grinder Other—Type of Building -----------------_-------- No. of persons-------------------------_-- Showers Cafeteria a ---------------------------------------------------------------------------------------------:3 ------------------------ Desig Other fixtures n Flow---------------- .t ,lions per person per day. Total daily flow--------------------------------------------gallons. P4 Septic Tank—Liquid capaci ... Ions Length................ Width---------------- Diameter-----------_--- Depth---------------- Disposal Trench—No..................... W* ..... Total.Length......_..._ ....... Total leaching area-_-_ sq ft. ----------- Seepage Pit No .............. Diametet*1k.......... Depth below inlet...... ........ Total leaching area__3 ft. Z Other Distribution box Dosing tank �4�_4 Percolation Test Resultj Performed by.......................................................................... Date---------------------------------------- Test Pit No. 1.... minutes per inch Depth of Test Pit.................... Depth to ground water-__-_-__-_____-___-.._. w Test Pit No. 2................minutes per inch Depth of Test Pit._____........_..... Depth to ground water---------------- r ...... ... ............................................... I -------- ---------------------------------------------------------------------------------------------------------------------------- 0 Description of Soil............. ....... ---------------------------------------------------------------------- U ....................................................................................................................................................................................................... W Z --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ...........................................................................................................................--------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article X1 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Si Pd ---------------------------------------------------------------------- -------------------------------- Application Approved Y.-, ...................... ....... Application Disapproved for the following reasons:...................... --------------------------------------------------------------Date.. .............. .......................................................................................................................................................................................................... Date PermitNo..................................................!...... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD Q; HEALT17�o P :................OF........ ...... ... ........................................ At %urriffirate of MWOmpliatta TIIIS IS CERT,IF I the vidual Sewage Disposal System constructed or Repaired b ..... ..t. ... .......V... ...... ........ Y. X_- I S 11 -----------ff'o-------------­------------------ at.,...a. .............................. ... ....... ....... ............:.............. ... . .. ....... -------------- - ---------I....................................... has been installed in accordance with the provisions of'Ar le_'�� of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...................... ...... dated.....A---/--------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................... ........................................ ... Inspector... 7" ......................... -------- THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALT ..............0 F V/ ­ ........................................................... No... iE' FEE.. --------- ....... rkii TO tidion Permit Permission jyKe'reby granted....4/& ... ....V- - ------------------------------------------------------............................. to C o n s t P,6ict YV, 1 Ie air )/,hn Indivip ryal"Sewage Disposal System at No --- -- - ---------------------------------------------4..a1L- ---------------------------------- Street 7.4, as shown on the application for Disposal Works Constructi e in Dated-- -------------- ...................... .... ........... .. ----------------------- ----- ............................. DATE Board of H It FORM 1255 HOBBS & WARREN. INC.. PUBI71,,$,H,ERS