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0050 OLDHAM ROAD - Health
50 Oldham Road Osterville A = 120 - 105 f • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments_ M , 50 Oldham Rd Property Address Rosemary Davies Owner Owner's Name information is required for Osterville Ma 02655 7-24-14 every 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: A. General Information When filling out forms the computer, r, use 1. Inspector. only the tab key to move your Matthew F. Gilfoy cursor-do not use the return Name of Inspector key. B&B Excavation Company Name 14 Teaberry Lane Company Address Sandwich. Ma. 02644 Cit frown y State ,. Zip Code. (508)477-0653 S113640 Telephone Number License Number B. Certification f3 �z certify that I have personally inspected the sewage disposal system at this add Tess and t�gt 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 r`rtaintenarl of©msite sewage disposal systems. I am a DEP approved system inspector pursuant to.Section 15.340 of Title 5(310 CMR 1.5.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7-25-14 Inspector's Signaiure 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. 3 t5ins•3M 3 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 e 50 Oldham Rd Property Address Rosemary Davies Owner Owner's Name information is required for Osterville Ma. 02655 7-24-14 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: 1 have not found any information which indicates that any.of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 13 System Conditionally Passes: ) Y ❑ 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 0 ND (Explain below): - t5ins•3/13 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 ,•''r 50 Oldham Rd Property Address Rosemary Davies Owner Owner's Name information is required for Osterville Ma. 02655 7-24-14 every 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 I 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; j safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form I rW Subsurface Sewage Disposal System Form - Not for Voluntary,Assessments .'' 50 Oldham Rd Property Address Rosemary Davies Owner Owner's Name information is Osterville Ma. 02655 7-24-14 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public.Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than:100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory; for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and:nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to AILSystems: 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 El ® 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 '/2 day flow t5ins 3/13 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 50 Oldham Rd Property Address Rosemary Davies Owner Owner's Name information is required for Osterville Ma. 02655 7-24-14 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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 o'r.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. 1-11 ® 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 El El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-.IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments- M , 50 Oldham Rd Property Address Rosemary Davies _ Owner Owner's Name information is required for Osterville Ma. 02655 7-24-14 every 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 ❑ 0 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? y ® ❑ 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: Z ❑ 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): DESIGN flow based on 310 CMR 15.203 (for example: 1:10 gpd x#of bedrooms): 330. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .'� 50.Oldham Rd Property Address Rosemary Davies Owner Owner's Name information is required for Osteryille Ma. 02655 7-24-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information :.. Description: 1 Number of current residents: - 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 .N No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(god)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current _ Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 3.10 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 50 Oldham Rd Property Address Rosemary Davies Owner Owner's Name information is required for Osterville Ma. 02655 7-24-14 every page. Cityfrown 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: gaiions How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system El 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/Asystem 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 ,. 50 Oldham Rd Property Address Rosemary Davies Owner Owner's Name information is Osterville Ma. 02655 7-24-14 required for _ every page. CitylTown 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 2006 with existing tank Were sewage odors detected when arriving.at the site? ❑ Yes ® No. Building Sewer(locate on site plan): 14„ Depth below grade: feet. Material of construction: t ❑ 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.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank(locate on site plan): - I 8" Depth below grade: - feet Material of construction- ® concrete ❑ metal ❑ fiberglass El 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. Sludge depth: NS 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 .50 Oldham Rd Property Address Rosemary Davies Owner Owner's Name information is required for Osterville Ma. 02655 7-24-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlettee or baffle NS Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.) At time of inspection septic tank appeared to be in working orderjees present no sign of back- up.Liquid level equal with outlet invert: - Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: I Scum thickness Distance from top of scum to top'of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I �i i ' Commonwealth of Massachusetts c Title 5 Official Inspection Form } Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Oldham Rd Property Address Rosemary Davies Owner Owner's Name information is Osterville Ma. 02655 7-24-14 required for _ 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.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grader 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 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11.of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Oldham Rd Property Address Rosemary Davies i Owner Owner's Name information is required for Osterville Ma. 02655 7-24-14 every 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.): At time of inspection d-box appears to in working order no sign of deteration or carryover. it t Pump Chamber(locate on site plan): Pumps in working order: ❑ ;Yes ❑ No" Alarms in working order. ❑ Yes FT No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): r 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 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 50 Oldham Rd Property Address Rosemary Davies Owner Owner's Name information is required for Osterville Ma. 02655 7-24-14 every page. City/Town State Zip Code Date of Inspection D. System Information Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gallon ❑ 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 time of inspection leaching appears to in working order no sign of hydraulic failure. Leaching dry at time of inspection. Cesspools (cesspool must be'-pumped as part of inspection) (locate on site plan): Number and configuration ' Depth —top of liquid to inlet invert - Depth of solids layer Depth of scum layer Dimensions of:cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 50 Oldham Rd Property Address Rosemary Davies Owner Owner's Name information is required for Osterville Ma. 02655 7-24-14 every 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Y ..Commonwealth-of Massachusetts Tit e 5 Official inspection Form Subsurface Sewage Disposal'S.ystem Form -Not for Voluntary.Assessments 50 Oldham:Rd . Property Address Rosemary Davies Owner., Owners Name information is Osteryille Ma. 02655 7-24-14 required for. every page. Cityrrown State Zip Code Date of Inspection D.,System, Informati.on:(cont.) :. Sketch Of Sewage Disposa[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: '0: hand-sketch in the area below_ drawing attached separately Al . BIZ-aV �12 t5ins 3/13 Title 5 Official Inspection Form-Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of-Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 50 Oldham Rd . Property Address Rosemary Davies Owner Owner's Name information is required for Osterville Ma. 02655 7-24-14 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 high ground feet eetfeet 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: COC dated 5-3-07 Date ❑ Observed site (abutting pfoperty/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: No GW at 10' using USGS top maps You must describe how you established the high groundwater elevation: Plan on file Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ;Y r r. Commonwealth of Massachusetts Title 5 Official Inspection- Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments s 50 Oldham Rd Property Address Rosemary Davies Owner Owner's Name information is Osterville Ma. 02655 7-24-14 required for every 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t TOWN OF BARNSTABLE LOCATION SC3 O 4o, SEWAGE# .2007 VILLAGE OS ret"i //a ASSESSOR'S MAP&PARCEL 1.2-0 INSTALLERS NAME&PHONE NO. 14,e le-se t ,a Sr 17,71 -Y Ile SEPTIC TANK CAPACITY / 67D 0 LEACHING FACILITY:(type) 5Z0 d* (size) /,3Ifs f xa1(7 NO.OF BEDROOMS OWNER PERMIT DATE: S" t a 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 . � . ;� IQ i�. 3 2� d r A " '� �f� y�1� �lk�ZAT10N 1 SEWAGE PERMIT NO. VIh LAG E O S'7172 INSTA LLER'S NAME & ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 7� --t/Z) CIS 6 , s y . .. ,r a —'" _. Y - e .. .. }. — •_ No. 0 h Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIPPYication for Dio"Upgrade �pgtem� Conttructiou Permit " Application for a Permit to Construct( ) Repair( ) ( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. O Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �41,e—k�' asv S 9Y 6V�-99oZ 3k J2 ,�, �,,►, 362- Sy Type of Building: Dwelling No.of Bedrooms Lot Size Iva sq.ft. Garbage Grinder (A) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 30 gpd Design flow provided �Y "9 gpd Plan Date Mew /, 02007 Number of sheets Revision Date Title Size of Septic Tank s s dt7a Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signe Date Application Approved by Date Application Disapproved by: Date for the following reasons a Permit No. Date Issued No. _ � j -` Fee i a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION'- TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIpprication for Mi5pogal 6pgtem ConotructioH Permit Application for a Permit to Construct O Repair(') Upgrade O Abandon O ❑ Complete System ❑Individual Components Location Address or Lot No. iD O� � Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address and Tel No. Designer's Name,Address and Tel.No. Name, h/ ( ASS S"`e-6gk-99aZ 3k -Ig � / %.� �.:� p \342-- TY ! Type of Building: Dwelling No.of Bedrooms Lot Size 16, 906 sq.ft. Garbage Grinder (f Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3D gpd Design flow provided 3 gpd Plan Date &y AnD1 Number of sheets Revision Date Title Size of Septic Tank Pam. it�*1 A,CrDb Type of S.A.S. Description of Soil ( Nature of Repairs or Alterations(Answer when applicable) Date last inspected: #` Agreement: r 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. )� )a %/ f Date A lication Disapproved b ' PP PP Y� V � Date l for the following reasons Permit No. / Date Issued 9 ----------- —--------------- i t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( . ) Repaired (✓ ) Upgraded ( ) Abandoned( )by �4 '1 ,a Vt Sv, at .50 �� QS �Y,r. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer N��<�.y �r,,atG Designer #bedrooms 3 Approved desi�.n flow 3�/ / /� gpd The issuance of this permit shall not bi c s rued as a guarantee that the system wiN function as designe', C Date Inspector ---------------- ———————————--- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS x1h6p dal 6p.9tem Construction Permit Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon ( ) System located at S-0 O k� VIN.-.w. "Apt-- and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty ' to comply with Title S and the following local provisions or special conditions. , Provided: Con tructfon must be completed within three years of the date of this p Date i Approved by �! ` Town of Barnstable ' Regulatory Services Thomas F. Geiler,Director " ' • Public Health Division M,Re Thomas McKean, Director 200 Main Street,Hyannis, MA.02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: 1 D Sewage Permitg - '� Assessor's Map\Parcel - Designer: 0 Installer: b Address: P\ V t— Address: �g On ve �ays `� was issued a permit to install a 4a( te)- ( taler )) i septic system at � D (/' � - based on a design drawn by ( ess dated 1 (d er) giL I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance vArith State & Local Regulations. Plan revision or - certified as-built by designer to follow. OF r4,,y8 0 ARNE H OJALA ( ns ees Signature) CIVIL No130792 GISTER�OC��� R� /GNAL (Designer's Signa ure) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.doc le Complete items 1,2,and 3.Also complete A.rm�- item 4 if Restricted Delivery is desired. Agent ■ Print your name and address on the reverse XAddressee so that we can return the card to you. B. Received by( tint Name) C. Date of Delivery ■ Attach this card to the back of the mail piece, or on the front if space permits. 1. Article Addressed to: D. Is delivery ad different from item 1? ❑Yes If YES,enter delivery address below: o MsNamy O'Conner 50 Oldham Road 4.; ` 3. Service Type Ostervi.11e,1V1A 02655 Mall ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. /% 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number ,f,,j 7 0 05 116 0 00 00 s`01,91 312 7, (Transfer from service label PS Form 3811,February 2004 Domestic Return Receipt 102595-02-W1540 UNITED STATES P 'ft*XV M-Ai ' . � Y, w �'w FCC aF�s' 64 �"�.. ,.l3i.i�rC� .���4yp.�' �b'�:r�; <? �, '..x,�: ermft•1�:��'8"�...�. ' • Sender:Please print your name, address,and ZIP+4 in this box• PUBLIC HEALTH DEPARTMENT TOWN OF BARNSTABLE i 200 MAIN STREET HYANNIS, MA 02601 I I 1 !! iiillP } 11 1}7 •ktiit 1 17 iiiil }•1 I! r`ru D . m °' F F I C I A L f -S . a QPostage $ . f�'� p Certified Fee 0 5 to rZI p � O Return Reoeipt Fee t/) Astmeark (Endorsement Required) • 'Y p ResMctad Delivery Fee i / (Endorsement Required) ,� Ei t a Total Postage&Fees Fs 6 Lr) p SeM o p � Street Apt No.; —� ( ---------- ----------------------- or Po Box NZ. Q -- ------ -----------•---------------- City,State,ZIRt4 ••-------- Certified Mail Provides:a A mailing receipt (asienaa)aooz aunp`ooee wi0=1 sd n A unique identifier for your mailpiece n A record of delivery kept by the Postal Service for two years - Important Reminders: o Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. o Certified Mail is not available for any class of international mail. e NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional-fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. n For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mallpiece with the endorsement"Restricted Delivery". o If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. if a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. Internet access to delivery information is not available on mail addressed to APOs and FPOs. Town of Barnstable FtHE)� do Regulatory Services Thomas F. Geiler, Director + aARNSTABLE. 9$ 1mr Public Health Division Thomas McKean, Director 200 Main Street,Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 April4, 2007 Ms Nancy O'Conner 50 Oldham Road Osterville, MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system owned by you located at 50 Oldham Road, Osterville,MA was last inspected March 8th, 2007,by Ron Burlingame, a certified.septic inspector for the State. of Massachusetts. The inspection of your septic system showed that your system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. Static liquid level, due to a decayed (collapsed) distribution box, is above outlet invert. Leaching pit was full at time of inspection. You have 1 year from the date of the system failure to bring the system into compliance. If there are any questions about this reminder,please feel free to contact the Barnstable Health Department. BARNSTABLE HEALTH DEPARTMENT Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS + d DEPARTMENT OF ENVIRONMENTAL PROTECTION a Sy4 TITLE 5 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM . PART A 1,;20 J O S CERTIFICATION Property Address: 50 Oldham Road , Osterville,MA Owner's Name: Nancy O'Conner Owner's Address: 50 Oldham Road,Osterville,MA Date of Inspection: March 8,2007 Name of Inspector: (please print) Ron Burlingame, Company Name: Ron Burlingame Mailing Address: 58 Oak Street West Barnstable,MA 02668 Telephone Number: 508-420-2050 ' CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on'my training and experience in the proper function and maintenance of on site sewage disposal systems,. I am a:DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: '= Passes ;. Conditionally Passes j > Needs Further Evaluation by the Local Approving Authority X Fails Inspector's Signature: I Date: The system inspector shall submit a copy of this` spection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 1 I k OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) r Property Address: } Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or E'/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. g 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 off sewage backup or break out or high static water level in the distribution box due to broken.or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced P 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: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: 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. The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet•or-more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: r Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: , You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded br clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen 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.] YES (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure.. E. Large Systems: s To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,.or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the.SAS,located on site X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. . X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CUR 15.302(3)(b)] • k" Page 6 of 11 R OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION F ., Property Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 ' Does residence have a garbage grinder(yes or no):No Is laundry on a separate sewage system(yes or no): No [if.yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use: (yes or no):.No Water meter readings,if available past 2 years usage(gpd)): Sump pump(yes or no):No Last date of occupancy: Current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: N/A Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined?. Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool —Overflow _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: 1978 Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of constriction:_cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): = SEPTIC TANK: X (locate on site plan) Depth below grade: 1' Material of construction: X concrete ' metal_fiberglass polyethylene _other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 1000 gallon Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee.or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Trees and shrubs have to be removed for covers to be opened. GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): „ _ Y r Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Y. SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal . fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X. (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: D-Box was decayed(collapsed). Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER None (locate on site plan) Pumps in working order(yes or no): y Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n M i � F Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type 1 leaching pits,number: 1000 galllon pit with stone. leaching chambers,number: leaching galleries,number: leaching trenches,number,length: 1 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.): Full at time of inspection. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) , Number and configuration: ' Depth—top of liquid to inlet invert: Depth of solids layer: p' Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):' PRIVY: (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.): , i f Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: 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. Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SITE EXAM Slope r Surface water Check cellar Shallow wells Estimated depth to ground water 12 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) ` Accessed USGS database-explain: You must describe how you established the high ground water elevation: No.......... — F>5..�. .. THE COMMONWEALTH OF MASSACHUSETTS I BOARD OF HEALTH ................OF... .................. ....................... Appliration for Big og4l Workii Tunfitru.rtuan Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: , .... ........... as tom••-•-- --._-- --- T. yy.......................................... L a on-Addr ss L/ or Lot No. r -----'.....•....----- •--___.=6 . , . ................................................................. w Vb � C OwnerC ss........................................... Installer Address Type of Building Size Lot.....h6_j:!®(t!.....Sq. feet ,-.-, Dwelling—No. of Bedrooms..---_-_--_•.•____ ______________________4Expansion Attic (_ ) Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria p' Other fixtures ................................. . W Design Flow..................%5...................gallons per person per day. Total daily flow................. Q--..............gallons. e. WSeptic Tank—Liquid capacity. .gallons Length.�.-�__- Width-! -_1d_, Diameter________________ Depth-_5'�__... x Disposal Trench—No. .................... Width....e.............. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._-_--'--I........... Diameter........ .__..._. Depth below inlet tal leaching area.....°r�_. __sq. ft. z Other Distribution box ( :T Dosingtank ( ) Z P _ '-' Percolation Test Results Performed by._ 'Y _-•=__ °J� P� Date------- _ .. ,aa Test Pit No. 1........ .....minutes per inch Depth of Test Pit------- _a0------: Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --•-------•--••----------------•----•-•---•--•--•--•--...-r:--......_._....._..........---•-------------------- •--------- ------- ---------------------------- O Description of Soil_______________ A 3�5..........45a*_�__- -:_. -•-••...............•---'-'------'-•'-'•-'•'••----'----...••••-••--......_•-••••---•-•'•-'-- W ..............._-------------_____------------------------------------------------------------------_________________......?........................................................................... UNature of Repairs or Alterations—Answer when applicable----------_______c_.....___________._..____________........._..........._..._..._..._.._....__. .............•••'•-•---•--•-'-•••-----'•-'•-••---"•...._...-•"......•'•----•••-••......._..••'-•-'-•••'•"•'----•-•---'•-•--'-'-•-'•-•-•-•-"-••---••-•-•'•-•-••••--••-••--......•'•'•-.___.......... Agreement The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with the provisions of TIT E 5 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 '--•' •-••- ....•--'-•'•-'-_..--•_-- Date Application Approved By •- -'•----------------- Date 1 Application Disapproved for the following reasons:..........................--•-•-•--------•--•-••--•---•-----'•......•---•••-••-•-•-----'-- ---------------4. Date Permit No......... '_.._....•-----'-•-----••-•-_. Issued. Date e 11 No......... .... FER............................. .......... THE COMMONWEALTH OF MASSACHUSETTS BOXRD� OF HEALTH 'o 14..................0 F.... .......... --------------------------------------------- "Alipfiration for Dispolial Workii To"witrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Di§posal System at: -71 eA ......................... .... ....... OMRIAXAV ......20A Q,�.:...( �.W?Jzuzca...... ..... ... ........._...._: or Lot o. �oddfioinAddress ...............................�..t....... ......... ......... ......... .......................................................................... Owner r A dress tii 44f... .. ............................................ ........ ........ -----------------*-------------*......."---------------- Installer 09 �ddrkess IL/ - 'Y .-Type of Building Size o t..... tn___Me.....Sq U Garbage Grinder Dwelling-- No. of Bedrooms..........................................Expansion Attic Ot PL4 P Other—Type of Building ..............-...........,,No. of persons............................ Showers Cafeteria Otherfixtures ------------------------- ................ ..........................................................I................................................. Design Flow. SS...................gallons per person per day. Total daily flow__._............. !..._........_...gallons.� 9 Septic Tank—Liquid capacity.I V&..gallons' 'Lengt*h.�6.f/_,n*'.. Width.4�!t1!>". Diameter________________ Depth..5.-Rc."... Dlkposal trench—No..._......_. Width:_: Total Length..................... Total leaching area................. ....Sq. ft. Seepage Pit No.........I........... Diameter........6 ... ....... Depth below" . . .... Wtv&l leaching area.....U.Q.-sq. ft. z Other Distribution box ( -wor 'Dosing tank -; Percolation"Test Results Performed -------- ........... Date... . Jz.q_ Test Pit No. i.......t...._.minutes per inch Depth of Test Pit-------1.7....... Depth to ground water___-_-__-.............. Test Pit No. 2...............minutes per inch Depth of Test Pit____._.._..._....... Depth to ground water.___._........_.....___. .................................................. ................................................................................................ 0 Description of Soil................ ---------S&ilttm.............I............................................................................................ ..................................................................................................................................t.......................................---------------------------------- U ---------------------------------............................I------------------------------------------------------��!r............................... -------------------------------------------- U Nature of Repairs or Alterations+, Answer,.mhen applicable--------.......................................................I.............................. ............................... ...................................:.............................7..................................7........ ...............wr....................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT 1L . 5 of the State Sanitary Code— The undersigned.J&ther agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Si 46, -A ---------- -------------------- ApplicationApproved By.-/ ........................................��40:61....................... ........................................ 'Date Application Disapproved for the following reasons:............................................................................................................... ................................................................................................................................................................................................-------- Date PermitNo......................................................... Issued...................................................... Date THE COMMONWEA,I.TH OF,MASSACHUSETTS BOARD HEALTH, 11 1 . ........ ................OF............el ...................................................................... (9rdifiratr of Tomptiaurr T, S 0 a Individual Sewage Disposal-S)rsten�.constructed or Repaired "I------------------------- by ....... . ... .... ... ........... ----------- .. ...... .................. ....... ................ ................ .... ..... . .. ........... aller ;4v at.....r................................... ------------ ------------------------/- --------------- I T a has been installed in accordance with the provisions of he State Sanitary ode de in the application for Disposal Work . . -s'Construction Permit N ......... ..................... dated-.'!--------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......® 4...................................... Inspector.. .................................. THE COMMONWEALTH OF MASSACHUSETTS .. BOARD ,,,,.P F HEALTH....-OF...4 ...... Mf ......................... ... No.......... L&... F . ........ For on Minn permit Permission ereby gr. 40 . .......... .......... . ............................................................................................ to Consti or ReDaW* ndi Se du I ispos at ... ........ ... ..... ... .................................No.. ...................!!Z......&S,trV Street as shown on the application for Disposal Works Construct' P No./� t d.......... - "71------------ ---------------------------- --- Board of Health" �/ DATE................................................................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS per=tG}..t T�ATA. L_t0 C-sAG�KL�!t� (�%fzl tJt7�.� »_-•.. reAtl_�{ G'WW � Itt� � 3, t �'3b G•PTJ. �E�'''1<'i c 'f"I�t�t iG = �'30./ I�JG %. • d.��j 6.P v. lJ S� 1 OOC:�. h1SFOS AL. PST - l)St= l o .�►,at_.. �. ■/Mee.io�rsvrwanr rr+�rM■�,li e.ri Y■�r■�ri pr1�e■■irewr■n� '5C> yam. A 1 ,C> ; = " 50 C--,:#'D, . }' TOTAL TJESIGtJ c-.-2 pn• p"- T-OT•oL ID.&i L,4 lt..ovw vt=ucoLetlo�.1 Ra-t� t ►U 2Mtu= orz tom.: _ 4L 44 RRJAARV MR �- "� mod'� " •" I To! FKp a Io.aa ` �V/R!� a �M!� !,�_Y - \e � \.♦N. � ♦ � tug• ��.� b 1!" I 000` tuv 'fox 94 4 IQi�IV. ( 1 +�AWK 1000 'u�, tt�i j Il 1 AILS L6A�A Eu Pt��iL_� LbCAtION ' t6uAIaX pgx- I C t:;tz T L E_`( T"A-P T t4 G .' 4t1Ge. SN N Pt Q M,.t R i*�» 1-l�:k'tsCs��1 Gc�vV��L�(S W ITI-1-'1't-1:c: �jlDir t-1►-aE: a�.C3T. Z 7 Auc> SE=-r1lACIC Vr--4UIQGAAa ITS Dt= `� ,, // �rO w W ot=°► $ Q t l�i OTrm\/i LL$ ;�•l oco S k3 A jCT�.k'.. 4-` W YF-- 1*-JG- {ZGGI�IZ tZi=D 't A WO iU��i�`fiUtL a c WoT OSTE �/tl.t,L= o ►tJtif�.�/✓tt,:t.i i ltUt�•lk;y' � TLC. C3i+�'S�(-�, ildlui:,JLD n.�ta't�t �li.t:_1'T' u-.cr,,) r-c., oe:.j7r-CMS`4E:r Lc>T ..t,I WCE: --Dumj pie,po2%___�� twea . SYSTEM PROFILE NOTES TOP FNDN. AT EL. 39.9' ACCESS COVERS TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) Route 28 ACCESS COVER TO WITHIN 3" OF FIN. GRADE 1. DATUM IS APPROXIMATE NGVD ACCESS COVER (WATERTIGHT) TO 39.0' MINIMUM .75' OF COVER OVER PRECAST /` WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 2. MUNICIPAL WATER IS EXISTING 39.0 Q 38.0' RUN PIPE LEVEL 2" DOUBLE WASHED PEASTONE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. *EXISTING FOR FIRST 2' OR GEOTEXTILE FABRIC "EXISTING 1000 3' MAX. 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO ' *EXISTING GALLON SEPTIC TANK * 6 " MP 36.3' -E 35.73' �� 35.56' QQQQ O Q Q Q Q 5. PIPE JOINTS TO BE MADE WATERTIGHT. LOCUS °rnps�i 35.5' Q Q Q Q Q QQQQ 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH 6" CRUSHED STONE OR MECHANICAL Q Q Q Q Q Q O Q Q MASS. ENVIRONMENTAL CODE TITLE V. COMPACTION. (15.221 [21) 2' QQQQ Q QQQQ o 33.5' DEPTH OF FLOW = 4' 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO o- TEE SIZES: 3/4" TO 1 1/2" DOUBLE WASHED STONE BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE. INLET DEPTH = 10" OUTLET DEPTH = 14" ( 4 % SLOPE) ( 1 % SLOPE) 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. FOUNDATION EXISTING SEPTIC TANK 20' D' BOX 8' LEACHING 59 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED FACILITY WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION *THE INSTALLER SHALL VERIFY THE **THE INSTALLER SHALL CONFIRM MIN. OBTAINED FROM BOARD OF HEALTH. LOCUS MAP LOCATIONS OF ALL UTILITIES AND ALL SEPTIC TANK SIZE AT 1000 GALLONS AND 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING SCALE: 1" = 2,000't BUILDING SEWER OUTLETS AND ELEVATIONS ITS SUITABILITY FOR RE-USE DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION PRIOR TO INSTALLING ANY PORTION OF BOTTOM 1H-2 EL. 28.5' OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO ASSESSORS MAP 120 PARCEL 105 SEPTIC SYSTEM COMMENCEMENT OF WORK. LEGEND 11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND LOCUS IS WITHIN WP OVERLAY DISTRICT REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. 100.0 PROPOSED SPOT ELEVATION 12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE REMOVED 5' BENEATH AND AROUND THE PROPOSED +100.00 EXISTING SPOT ELEVATION LEACHING FACILITY. 100 0 PROPOSED CONTOUR SYSTEM DESIGN: 100 EXISTING CONTOUR ^� �k GARBAGE DISPOSER IS NOT ALLOWED �`o ip3 8�• DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD �% USE A 330 GPD DESIGN FLOW 0' LOT \ SEPTIC TANK: 330 GPD (2) = 660 6 16,706 SFt TM-z L� DocHoust **RE-USE EXISTING 1000 GAL. SEPTIC TANK TM- 4" TREE LEACHING: .... TEST HOLE LOGS ', `._:• O~ � ,- c oTH§LINE SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD F� BOTTOM 25 x 12.83 (.74) = 237 GPD ENGINEER: DAVID FLAHERTY, R.S. 4-A ` � ) WITNESS: DONNA MOIRANDI, R.S. HOL BUSH L^ /,' .\` TOTAL: 472 S.F. 349 GPD DATE: APRIL 30, 2007 BENCHMARK lb CORNER OF CONC BULKHEAD 10" TREE ./' GARDEN '' USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) q. /PERC. RATE _ < 2 MIN/INCH ELEV = 38.9' 0 ,/' 41 WITH 4, STONE ALL AROUND CLASS I SOILS P# 4 H� `• � / ELEV. ELEV. ���/ SUNROOM ` ```/`• SMALL \`/ MA _ 4 _ 4 (ON �O HEDGE p" 38.8' p" 38.5' EwsnNG 3�R ' \ TUBES) APPROVED DATE BOARD OF HEALTH DWELLING A �� TOP FNDN=39.9' \ TRELIIS LS LS 10YR 2/1 10YR 2/1 G' caTv TITLE 5 SITE PLAN 3" 38.5' 4" 38.2 ��, `-, /, ,�� B B "rn / OF LS LS R 4/6 36.8 " 10YR 4/6 TEL GARAGE 50 OLDHAM RD. 24" 10Y 25 36.4 TE O (OSTERVILLE) BARNSTABLE, MA PREPARED FOR PERC �F HICKEY CONSTRUCTION MCS PAVED MCS e ` � �� DRIVE � ,� DATE: MAY 1, 2007 38 Scale: 1 = 20 2.5Y 5/6 2.5Y 5/6 ��N, s�'tiF ' ,� 0 10 20 30 40 50 FEET / off 508-362-4541 ��` 37 ��ZH OF Mgssq ��ZH�F MAss9 fax 508 362-9880 DANIELA. cyGN� �°�� DANIEL �yGN OJALA A.' `� � � CIVIL OJALA � 120" 28.8' 120" 28.5 down cope en gin e erin g, Inc. �No.4098G Cl VIL ENGINEERS NO GROUNDWATER ENCOUNTERED ` \`\ ,�j�l �b� •PpF�FGISTS �N � �9 FsR �°�' LAND SURVEYORS NAL J 939 Main Street - YARMOU THPOR T, MASS. DCE #07-051 DATE DANIEL A. OJALA, P.E., P.L.S. 07-051 HICKEY CONSTRUCTION.DWG (DDF)