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0005 OLDHAM ROAD - Health
5 OLDHAM ROAD, OSTERVILLE A=120-078 f - j F iRL Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form !.Not for Voluntary Assessments 5 Oldham Road Property Address W Richard Sargent Owner Owner's Name information is a S rylll O to e ✓ MA 02655 � required for every 08/06/15 page. City/Town `State Zip Code Date of Inspection' C4 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:out forms A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your. cursor-do not Mike Hudson . use the return key• Name of Inspector Septic-wiz Environmental Services rab Company Name - - - 31 Midway Dr Company Address Centerville MA 02632 City/Town State Zip Code 508-36775669 DEP SI#4254 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 08M 1/15 Inspector's Signature Date. The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,.the inspector and the system.owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments ^M 5 Oldham Road Property Address Richard Sargent Owner Owner's Name information is required for every Osterville MA 02655 08/06/15 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: 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 passinspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years.old is available. ❑ Y ❑' N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 5.Oldham Road Property Address Richard Sargent Owner Owner's Name deformation is required for every Osterville MA 02655 08/06/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken.pipe(s) are replaced ❑ Y . ❑ N ❑.ND (Explain below): ❑ obstruction is removed ❑ Y .❑ N . ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth mon ealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Oldham Road Property Address Richard Sargent Owner Owner's Name information is required for every Osterville MA 02655 08/06/15 • page. City/Town State Zip Code Date of Inspection. B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. - ❑ The system has a septic tank and SAS and the.SAS is less than 100 feet but 50 feet or more from a private water supply;well**: Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All.Systems: You must indicate "Yes. or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the starface 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 1/2 day flow l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 5 Oldham Road Property Address Richard Sargent Owner Owner's Name information is required for every Osterville MA 02655 08/06/15 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. El ® 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. El ® 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 2000 d- Y P 9 Y 9 9P 10,000gpd. y The system fails.] 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 atributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zoneal 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 li 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 Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Oldham Road Property Address Richard Sargent Owner Owner's Name information is required for every Osterville MA 02655 08/06/15 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. ❑. Z 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 z#of bedrooms): 330 GPD t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Oldham Road Property Address Richard Sargent Owner Owner's Name information is required for every Osterville MA. 02655 08/06/15 page. City/Town State Zip Code Date'of Inspection D. System Information Description: 3 Bedroom cape < III Number of current residents: Unoccupied Does residence have a garbage grinder? _ ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? Yes ❑' No Water meter readings, if available last 2 ears usage d 2013-326 GPD _ 9 ( Y 9 {gP ))� 2014-326 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown r 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I ` 5 Oldham Road i^M Property Address Richard Sargent Owner Owner's Name information is Osterville MA 02655 08/06/15 required for every - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: date Other(describe below): General Information Pumping Records: Source of information: Barnstable BOH Was system pumped as part of the,inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping:' Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ 'Privy. ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 5 Oldham Road Property Address Richard Sargent Owner Owner's Name information is required for every Osterville MA 02655 08/06/15 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: 18 years, SAS installed 1997 via as-built and permit Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): . 28" . Depth below grade: feet,. Material of construction: ❑ cast iron ®40 PVC . ❑ other(explain): Distance from private water supply well or suction line: PP Y N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): vented thru roof, no leaks Septic Tank(locate on site plan): Depth below grade: 191, feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: 'N/A years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate)' ❑ Yes ® No Dimensions: 5'8"Wx10'6"Lx5'8"H - 1500 gallon • Sludge depth: 4'8" (4"thick) t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 5 Oldham Road Property Address Richard Sargent Owner Owner's Name information is required for every_ Osterville MA 02655 08/06/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 22 Scum thickness 6„ 4„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 18 y How were dimensions determined? Sludge probe, tape, LED camera snake, floodlight 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 should be pumped every 36 months, inlet and outlet PVC tees in-good condition, tank appears structurally sound w/liquid at normal operating level, no signs of leaks in or out of tank at time of inspection. Grease Trap (locate on site plan): Depth below grader 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 I Distance from bottom of scum to bottom of outlet tee or baffle Date of last.pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °w 5 Oldham Road Property Address Richard Sargent Owner Owner's Name information is Osteryille MA 02655 08/06/15 required for every I page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons , Design Flow: gallons per day Alarm present: ❑ Yes ❑ -No _ Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm.and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts assac setts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - M 5 Oldham Road Property Address Richard Sargent - Owner Owner's Name information is Osteryille MA 02655 08/06/15 required for every ` page. City/Town State° Zip Code Date of Inspection D. System Information (cont:) 4 Distribution Box(if present must be opened) (locate on site plan): " Depth of liquid level above outlet invert even.w/.(2) outlets 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 level, liquid even w/(2) outlets, no solid carryover, no signs of leaks in or_out at time of inspection. Top of d-box 24 below grade. PumpChamber locate on site Ian ( 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.): f * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 5 Oldham Road Property Address Richard Sargent Owner Owner's Name information is required for every Osteryille MA 02655 08/06/15 page. City/Town State Zip Code Date of Inspection D. System Information(cont.) Type: , ❑ leaching pits number: ®' leaching chambers number. (2) 500 gallon ❑ leaching galleries number: ❑ leaching trenches number, length: El 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.): Med sand, no signs of hydrauluic failure, no damp soil or abnormally lush-vegetation, SAS (2) 500 gallon concrete leach chambers w/stone around. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth.—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M •''� 5 Oldham Road Property Address Richard Sargent Owner Owner's Name information is required for every Osterville MA 02655 08/06/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): r t5ins•3/13 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 M 5 Oldham Road Property Address Richard Sargent Owner Owner's Name information is required for every Osterville MA 02655 08/06/15 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 s . . t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts - W Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 5 Oldham Road Property Address Richard Sargent Owner Owner's Name information is Osterville MA 02655 08/06/15 required for every page. City/Town State Zip Code. Date of Inspection D. System Information (cost.) Site Exam: ® Check Slope _ ® Surface water F ® Check cellar ® Shallow wells Estimated depth to high ground water: 12 fleet Please indicate all methods used to determine the high groundwater elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: pate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: reviewed'as-built card ❑ Checked with local excavators, installers (attach documentation) ® Accessed USGS database-explain: Reviewed USGS water resource and topographic maps You must describe how you established the high groundwater elevation: Reviewed USGS topo and water resource maps. Reviewed as-built. Bottom of SAS at 60".xGround water 12'+. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins-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 M 5 Oldham Road Property Address Richard Sargent Owner Owner's Name information is required for every Osterville MA 02655 08/06/15 page.. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information_Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on,page 15 or attached in separate file t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 •� -TOWN OF=BARNSTABLE LOCATION _ {(�L��ta.t ` SEW& #QA > VILLAGE s� ✓f/ / ) ASSESSORS MAP& LOT 'INSTALLER'S NAME&PHQNE NO. ram' SEPTIC-TANK CAPACITY x LEACHING FACILITY: (type) - -- (size) . :Diu NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: , '7//9 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the'Bottom of Leaching Facility, Feet Private Water Supply Well=and Leaching Facility (If any wells exist,. on site.or within 200 feet of Teaching facility) Feet _ Edge of Wetland and Leaching Facility:(Yany wetlands exist within 300 feet of leaching facility) ! 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APPLICATION FOP DISPOSAL SYSKM CONSTRUCTION PERMIT Application for a Permit to Construct(,_Repair( ) Upgrade( ) Abandon( ) - )(Complete System ❑Individual Components Location ® �� Lj` r�/�f� Owner's Name, Map/Parcel# [ Address 00 Xe e,,,- rVec Lot# Telephone# 2¢ Installer's Name Q e, ✓Ve Designer's Name 0C Address �� �l b✓��� ve V `�� Address t 6 4 L,(Q`�Jr.f e?e- Lze AZ' Gi ll Telephone# 5-40 — `301 �j Telephone# �q(® o Type of Building Il }P 6rA(A,-, t,, Lot Size sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow(min.required) gpd Calculated design flow 13 Design flow provided gpd Plan: Date Number of sheets Revision Date CO Title FJSe Description of Soil(s) She d 54e�e,7- ©T—_ Id ` Soil Evaluator Form No. ame of Soil EvaluatorJL4__r il)e! Date of Evaluation AS- DESCRIPTION OF REPAIRS OR ALTERATIONS The undersi gre the a ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further s to to the syste in operation until a Certificate of Corpplianci has been issued by the Board of Health. Signed Date "J 4� eC4 �. - ,..i. � ,� -.w r � `' �� `�T'�, + _.r .f.MLw:s..�f*cv C�,'✓`Y'•.{"e.-r`.. -i1",._ "` �r-.-'`y+r,-..,e.�- .. :'y�, f r �j No. FEE COMMONWFAd Board of Health, ��r h sad-6Ae , MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct Repair( Upgrade( ) Abandon( - Complete System ❑Individual Components Location D goad S,Tw lff Owner's Name Map/Parcel# I�Lco Address l©© Lot# Telephone# Installer's Name �0��, (-Q rv� Designer's Name s 5 oe S z Address l� v Mow Address t 6,4 L447k v;,i e Lee Ate- 101 Telephone# e�o Telephone# 5 t� OCR f`a� ADur Type of Building_ f�d7i/�1M ^ i �//P 1 c, 0 Ova- e-- Lot Size 1!�Q �0 s ft. q� Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) 9 Other Fixtures Design Flow(min.re wired) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title tD lQ — O(7e USA L/ TO0 YOM eG1 C 1 a w- i Description ofSoil(s) SeC �1 Lp 5r�c-e ©� l�(�.� n Soil Evaluator Form No. ame of Soil EvaluatotP 1`02�fh e/ Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS i The undersi gr� the ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and furthero res to oft the syste in operation until a Certificate of Complian has been issued by the Board of Health. Signed Date . ' _ / q ions a r No.�O �7� FEE r .�C®��� LT� OF MASSAC�ilJSETTS �dV 1� V'V' 11~.t1t Board of Health, Am"O e,I41-e MA. CERTIFICATE-Of COMPLIANCE Description of Work: ❑Individual Component(s) Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed),Repaired ( ),Upgraded ( ),Abandoned ( by: at h Wes, p has been installe D—acccoordance with the rovisioc�ns of 310 CMR 15.00 (Title 5) and the p�rov—ed design plans/as-built plans relating to application No. 0 '7Q dated " / Approved Design Flow % o (gpd) Installer Tp / /t/p Designer: PZifcaf� Inspector: Date: / The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Nc. ( O 7 FEE Board of Health, Ka-fHJ lx-5Ie , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Constr/ " uct) R pair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at �0// /�, 12ef 0 Sly► /1 as described in the application for Disposal System Construction Permit No. ���'Yd dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sul kin Co.Boston,MA Date Board of Health l.J TOWN OF BARNSTABLE LOCATION s 0. IC( C tvt SEWAGE #QdR V O . VILLAGE Q_<JeellZ 1 f).-7 ASSESSOR'S MAP & LOT I 'INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I LEACHING FACILITY: (type) (size) 6u r,g 1 NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: 7/_ 9 _COMPLIANCE DATE: . Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) Feet Furnished by MT D f76'33 P�B �l7 _t. r 77 90 rrL- ' A' 1 R I ml11 ul WarHStaule i' P_ 9�4 !6?� -- -- Department of Health,Safety,and Environmental Services ar Public Health Division Dated �- � ""t•� 361 Main Street,Hyannis MA 01601 } I wuarAnttt.gel I •' :�,.` •' ` '.� Time ' Fee Pd. In M 16 Date.Sched fuled • V ,SoihSuitaGilityAssessment for'S&dge Disposal , t ., w !' ♦a t W.� ltnessed By Performed LOCATION �c G'ENERAI'INE+()ft1VtATION Gd�' �/ G {�,,,,,,� (� Owner's'Neme �7uOµ � I'4d9�-S Location Address ' ('Mf r'4�Y' : f�v.t(fd1� tf'vl�r•t_S Address goy- 12z 4 F,ngineer'sName �QS[gN fN.G Assessor's MaplParcel: l o, NEW CONSTRUCTION REPAIR Telephone A 6 $` 6v 0 S ,, •. �• Ql.� . _ + Slopes(%) 2 Surfhce Stones I�o Land Use VQC '' N R ' f b ft Possibie Wet Area - ft` thinking WaterdWell Distances from: Open Water Body I . �. .' , l,&g ' 3o ftI z �_ft Property Line ft Other + • . . • Drainage Way: , I "!•'3 ? SKETCH:(Street name,dimensions oLlot,exact locations,of test holes dt pere leers_locate wetlands In proximity to i f t �, W/A .�. Parent material(geologic) d� ' Depth to Bedrock � ` - Depth to Groundwater: Standing Water in Hole: 1\1 0 Weeping from Pit Face ` Estimated Seasonal High Groundwater > Zp ]DETERMINATION VOkSEASONIAL'WGH WATERTAitLlr; Mcthod Uscd: in, Depth to soil mottles: in. Depth Observed standing in obs,hole: in. Groundwater Adjustment ft• Dcpth to weeping from side of obs.hole: Index Well N__.•_,_ •Reading Date: _ Index Well level• Ad.factor Adj.Groundwater Level .•___ j PERCOLATION TEST '>«:;><'.'tirti t . 2 tote :60 Observation Hole q Depth of Perc 5 r 1lme9V! Start Pre-soak Time Q "r Time End Pre-soak L 2, • Rate Min./inch Site Suitability Assessment: Site Passed X Site Failed: Additional Testing Needed(Y" Original: Public Health Division Observation Hole Data To Be Completed on Back—� Copy: Applicant ` LOG itulty#�_ ur,Cr oljsrltvKFION 110Lr soil Ulher Snll'I'exlllre Soil Color Mottling (Structure.Stones,nou►does.. Ikptlr from Soil I lorizun (USDA) (Munsell) Surface(In.) l pY�.3�Z I Y d -C 5 1 e,ti, o�-P ° -� to loYP- �� r"s 31rJAyew 3$+4-1 G� � Z clew sc UCC� dUsri VhT1O OG soil ,�Uther Soil Texture Soil Color mottling (Structure,Stones,Doulderef. Depth from Solltltlorizon (USDA) (Munsell) Surface(in.) 10�/P 3�Z �� ' _6rs! l oGam- ` 5 _ sub"* • t o�•l _ l� `b - � rr ih l b" y. I•�S-u.w� . �----- G z s.cam z•s �2 >� �/ s ur "P Oi;sCttV�•r1ON 11oLC O ': soil OtherSoil Texture Soil lot Co Mottling (Structure,Stones,tioulderes. Ilcplh from Soil ilorizon (USDA) s (tunsell) Surfnce(In.) loyr-V2, �° Z.s �l clew 3�-39 G r we 2,,5 '!2 GCS s�-�P Gz. . - ..� --- llCG1) 0BSratVATION ROLE LOG Soil other Soil'texture Soil Color Structure,Stones,noulderes. Depth from Soil ilorizon (USDA) (Munsell) Mottling Surface(In.) w 1 • R M � 1 *'Aboveflood ..-a.... - .- • �__.. wRRna IaAfE aQi . nd No ___ Yes ,hood bou a►Y ` S00 Abo Yea,..r , Within 500 year boundary No Yes — Within 100 year flood boundary No Yes I •-rb „ c urrin C rvittusMglgl'1g1 all occurring pervious material exist in all areas observed throughout the Does at least four feet of naturally area proposed for the soil absorption system? _ Yrvious A - ,if not,what is the depth of naturally occurring pe material? ('•'rtyinCatl�� I111100"approved by the i certify that onjq5 (dale)1 have passed the ve tinai Is analysis Was performs d by me consistent%vith Department or i;nvirotu men 1,1 Protection and that the above y . I . .:..:.,. —;,rd; :,d exncricncc described in 310 CMR 1 S.017. 1 -sa•3�---W W BSS t DRI x W 50.10 --w 4 s.91 o 50.79 DESIDN OLDHAM ROAD x50.00 1 LEACHING � 50.20 CATCH 50.92 y PUBLIC — 50' WIDE BASINS /50.23 MANHOLE LAND SURVEYING � M®��� ®50.89 MANHOLE CIVIL ENGINEERING " \ ®51.01 LANDSCAPE ARCHITECTURE x EDGE OF PAVEMENT 51.14 \ BSS Deeigo, Thoorporated t CBDH y�� 100.00' 55 0 49'41 6" W 5,1 .88% E E 8etmouth y oh�{}e OE640 N-&f 25 3 x It x 9. 50.78 BENCH MARK: TOP OF FAg 608 fi48 8315 cv ' l S 50• 74 CONCRETE BOUND 50.66 7WVI ;� 5 .844 ` ` �6 �z CABI E BOX LEACHING CHAMBERS 500 GALLON h o� 10' " 98 \TELEPHONE BOX W 4' APART END TO END ry I ' ( ELEC TRANSFORMER WITH WASHED STONE D-Box I � a: `: � LEGEND: BE7*EEN AND 4'ALL I I ' O - AROUND THE UN/TS — —j \ 12.8' x 29.0' 3 #� x 5a s EXISTING SPOT GRADE T s (�51.73 X 1 96 .. EXISTING FIRE HYDRANT 0 Q x 60. ' S9.3' '' — ` 52 s8 ; �4 PROPERTY LINE W O WAI o CONCRETE BOUND � V I~— of o :s. I O Z w ,EFFFEr �� ' , TEST PIT a — EDW1N h�� ry ` , I 55 OHw EXISTING OVERHEAD WIRES 1 0o cA < V SqFR774, TA K ' w EXISTING WATER MAIN E EXISTING ELECTRIC w " X SZ74 X e226 ' I ,p N 1 w O a Q 55 PROPOSED CONTOUR � ---\ 0 ` 1 I "� 7EC PROPOSED TEL., ELECT & CATV Z Q = O ►y PROPOSED WATER SERVICE Q p Z 6ry h y15 I r�74RA ., 2b i x. W 5288 x J L� J .� 2 .. . N NOTES: _ EL o Q -� X 8 1 ) x , o M Lq j o � PROPOSED THREE 1. HOUSE # J La OLDHAM ROAD ~ Q BEDROOM HOUSE r ' I l z/ O M P�• O FF EL 594 1 - / - 2. ASSESSORS MAP 120 LOT 78 J Z UJ Q j •t`� �5217 I l I l "y: 2-4 / 3. ZONING DISTRICT: RC LL Q cl- 2 to O 2.2 4.- FLOOD ZONE: ZONE C ?s x 80 5. SPOT GRADE ELEVATIONS ARE BASED" scale1" = 20' 5211 /Z ON AN ASSIGNED DATUM. BENCH MARK: date " x �5X x TOP OF CONCRETE BOUND: 50.66 ) x 2.52 JULY 1, 1998 drawn LOT �� RJW DFL TJB j2� checked � � 20 830 SF /. // X5&2o / job///�� / number 1 �. 98088 lo 55 -- 1 / x 84.e5 title / 49.41'36" E / 54---'�/��/ ����/ PLOT PLAN 1 OF 2 196.76' CBDH 23 drawing number P4 - 28 FF ELEV. 59.4 , INSTALL CONCRETE RISER AS REQUIRED TO BRING COVERS BSS WITHIN 12" OF FINISH GRADE D E >6 1 a N 57.5 57.0 LAWN. 56.5 57.0 FINISH GRADE minimum 2% slope 56.0 FINISH GRADE LAND SURVEYING CIVIL ENGINEERING PVC PIPE I 55.66 • . FIRST 2' SHALL LANDSCAPE ARCHITECTURE & FlTTINr.... . � " _ . 3 MAX 114 Per foot min. -t. BE` SET LEVEL CLEAN BACKFlLL , 3 � " 5.i.86 . CONCRETE LIQUID I-VEL 6" 1/4 Per foot 1/4" per ft. 'min. 54.67 FOUNDATION 55.0 gyp- 14' Bss Design. Iaoorporatea 54.56 0 •s,•us,7�4; • 2'(1/8'-1/2')peastone 164'Katharine lee Bates Rd 4 .;; ° 0 O EO O 0 i •ia •. Felaonnth lleseachnsette OE640 3� 54.11 �. a..eG.B. 54.31 53.94 %• 4 '► �•wa° O O O 0 •fit • .S 2' 5MU0.8W FA% 608.63&B= CELLAR FLOOR 51.86 %®�' �° o 0 0 0 01 s; �Ns� L---4' JI 4'-10" +"I+ 4OF ' WASHED STONE, �i3�.rEFFREY SEE NOTE 3. i►� EDIAnN RYTHE LLJ 22' 10'6 10' 16 4' cn SEPTIC TANK TWO 500 GA'°ON CHAMBERS Fc, O DISTRIBUTION Box SOIL ABSORPTION SYSTEM LO LO USE 1,500 GALLON AASHTO - H10 3 HOLE AASHTO - H10 PRECAST LEACHING CHAMBER - H10 PRECAST SEPTIC TANK (DB3) y _! DESIGN CRITERIA SUBSURFACE SEWAGE DISPOSAL SYSTEM � in 0 - NOT -TO SCALE r NUMBER OF BEDROOMS 3 bedrooms ' DESIGN FLOW 110 gpd/brm TOTAL DAILY FLOW 330 gpd W LIJ 0 GENERAL NOTES CALCULATIONS ON S M TEST HOLE DATA w o = f X a 1. All system components shall be installed in accordance SEPTIC TANK: LU in F PERCOLATI ON RATE: < 2 min inch with the State EnvironmentcI Code Title V. Minimum � / U a � Requirements for the Subsurface Disposal of Sanitary DESIGN FOR USE WITHOUT GARBr,13E GRINDER TAKEN BY: Jeffrey Ryther, PE Z < Z Sewc,le, and an local rules which may be f:-n�,!icable 330 gal/day x 200% = 6.60 gal/day WITNESSED BY: Jerry Dunning Q 1,500 al TANK MINIMUM REQUIRED . DATE: June 25 1998 �--� 5 •- 9 2. The t✓.�rnstable Health De artm �ent and En ir,�.:r must P 9 • 1,500 gal H10 SEPTIC TANK PROVIDED m o be notified when the system is installed, and prior to - � S back filling for inspection. SOIL LOGS F-' .� P 3:3. 't stone around the leaching pit shall consist of washed f a; Q a J s ranging frog- 3/4 do 1-1/2 inches in size and be free - J 0 z 'S01 ABSORPTION' 1 LSYSTEM: 3 ^ � o: z�-on, fines, and dust i, lace. The stone shall be covered -- � � � Q a g P �. tc3 0 with at least a 2 inch to r of wa^hed stone ran�ang from 2--5 )0 GALLON' LEACHING, CHAMBE'S _ND � 51:0 0 EL 51.7 0 A SANDY LOAM - A SANDY LOAM scale 1/8 to 1/2 inch .in size, and be free of iron, fines, c,d dust. TO END, 4' APART, WITH 'WASHED STONE EL 50.5 6' EL 51.45 3" NOT TO SCALE in place. BETWEEN AND ALL AROUND. . 5 LOAMY SAND g LOAMY SAND 4. The grade above and adjacent to the leaching facility shall slop: i I date at least 27 -event accumulation of surface water. EL 49.75 15" JULY 1, 1998 • LEACHING AREA PROVIDED: STATE 'iiTLE V C1 MED. SAND �- �•7 �" drown 5. Sewer pipe De 4" diameter schedule 40 PVC or equal C1 MED. SAND at 1/4 per foot (2%) slope. SIDEWALL=2(12.8'+29')x2.0'x(0.74 gal/sf/day) EL 47.83 38" EL 48.45 39" TJB = 123.73 C2 LOAMY SAND 6. Flow equalizers shall be installed �,� the ends of all outlet .�=as/day EL 47.58 41" checked pipes inside the distribution box. BOTTOM AREA= 12.8 x29 x (0.74 gal/sf/day) C3 FINE SAND . C2 FINE SAND job number 7. Contractor shall notify the Engineer if he/she encounters soil •274.69 gal/day 98088 conditions other tho,- those shown on the soil log. TOTAL LEACHING CAPACITY 398.42 gal/day title EL'41.0 120" EL 41.7 120" SSDS DETAILS '. • PERC. RATE: G2 MIN./INCH (Cl) PERC. RATE: Q MIN./INCH (C1) 2 OF 2 AT 5' DEPTH AT 5' DEPTH drawing number P4-28