HomeMy WebLinkAbout0064 OLDHAM ROAD - Health 64 Oldham Road
Osterville P
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a!i®_t 1.0 2016, 22:33 Jim The Inspector Man 5085349919 page 1
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®® Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
64 Oldham Road
Property Address t-►
O?
John Reen s
Owner Owner's Name f-►
information is
required for every Osterville MA 02655 10-4-.16
page. City/Town. State Zip Code Date of Inspection 'J
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
o �/93a
filling
the computer, .�`���\`` SN OF IMgSIR
111*
.
use only the tab 1. Inspector:
key to move your p
cursor-do not James D.Sears _' � DAMES .m'
use the return �
key. Nam®of Inspector U:
�'• t*� i
Capewide Enterprises, LLC
Company Name! �r ' ',
153 Commercial Street
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I ll l ll ll tlll�
Company Address
Mashpee MA 02649.
City/Town State Zip Code 1
508-477-8877 S1623 i
Telephone Number License Number }
B. Certification
1 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 t
Title 5 (310 CMR 15.000). The system: t
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® Passes ❑ Conditionally Passes ❑ Fails {
❑. Needs Further Evaluation by the Local Approving Authority t
10-4-16
spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board t
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit theL 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, f
""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.
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Oct, 10 2016 22:33 Jim The Inspector Man 5085349919 page 2
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Commonwealth of Massachusetts
Title 5 Official Inspection Form E
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Oldham Road
1
Property Address
John Reen
Owner Owner's Name
information is Q
required for every Osterville MA 02655 10-4-16 ;
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
i in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1500 Gal. Tank D Box and 16 chamber's.
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B) System Conditionally Passes:
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❑' 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
in if the existing tank is replaced with a complying septic tank as approved by the Board of
Health. t
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A'metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
' Compliance indicating that the tank is less than 20 years old is available. `
❑ Y ❑ N ❑ ND (Explain below):
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15ins.doc-rev.6116 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 2 of 17
Oct,10 201,6 22:33 Jim The Inspector Man 5085349919 page 3
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1
64 Oldham Road
Property Address ;
John Reen
Owner Owner's Name
information required for e le very Ostetville MA 02655 10-4-16
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired. t
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
'to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
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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):
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❑ 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
I 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
t �I
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•re4.6/16 Title 5 Official Inspemon Forth:subsurface Sage Disposal System•Page 3 of 17
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Oct; 10 20'16 22.33 Jim The Inspector Man 5085349919 page 4
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Commonwealth of Massachusetts l
TitleZ Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments j
rY 64 Oldham Road
Property Address
John Reen _
l
.Owner Owner's Name ¢
information is required for every Osterville MA 02655 10-4-16 11
page. City/Town State Zip Code Date of Inspection r
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, F
safety and environment:
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❑ 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, e
0 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 t
i 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:
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D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No ,
0 ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
0 ® Liquid depth in is less than 6" below invert or available volume is less
than %2 day flow
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Oct 10 2016 22:33 Jim The Inspector Man 5085349919 page 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i
64 Oldham Road
Property Address
John Reen
Owner Owner's Name
information is required for every Osterville MA 02655 10-4-16 I page. Cityrrown State Zip Code. Date of Inspection
B. Certification (cont.)
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Yes No
El ® Required pumping more than 4 times in the last year NOT due to clogged or i
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
•❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.] .
El ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000g pd. !
❑ ® 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, F
Yes No t
❑ ❑ the system is within 400 feet of a surface drinking water supply
1 ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section•D shall upgrade the i
_ system in accordance with 310 CMR 15.304.The system owner should contact the appropriate I
regional office of the Department.
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Oct, 10 2016 22,34 Jim The Inspector .Man 5085349919 page 6
o Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 'Y I
64 Oldham Road
Property Address
John Reen
Owner Owner's•Name
Information is required for every Osterville MA 02655 10-4-1.6
.
page, City/Town State Zip Code Date of Inspection
C. Checklist
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Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No l
❑ ® 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? i
® Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction, i
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)]
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D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
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DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
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Oct 10 2016 22:34 Jim The Inspector Man 5085349919 page 7
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Oldham Road
Property Address I
John Reen
Owner Owner's Name
information is required for every Osterville MA 02655 10-4-16 i
page. City/Town State Zip Code Date of Inspection
D. System Information
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Description:
The system is a 1500 Gal. Tank D Box and 16 chamber's
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Number of current residents: 0
Does residence have a garbage grinder?
El Yes ® No I
Is laundry on a separate sewage system? (Include laundry system inspection '
information in this report.) ❑ Yes ® No
Laundry system inspected?
❑ Yes ® No
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Seasonal use? ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)): 2015-273,000Gall
2016-59-000 Gal's
Detail:
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Sump pump? b
i ❑ Yes ® No
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Last date of occupancy: NA i
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
I
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis.of design flow (seats/persons/sq:ft., etc.): --
Grease trap present?
t ❑ 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:
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Oct 10 2016 22:34 Jim The Inspector Man 5085349919 page 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form i
i
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v 'ti 64 Oldham Road
I Property Address
John Reen
Owner Owner's Name
information is
required for every Osterville MA 02655 10-4-16 L
page. Cityrrown State Zip Code Date of Inspection t
D. System Information (cont.) E
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Last date of occupancy/use: €
Date
Other(describe below):
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General Information
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Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No I
{ If yes, volume pumped: gallons
How was quantity pumped determined?
Repson for pumping:
Type.of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool E
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
El 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 i
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❑ Tight tank. Attach a copy of the DEP approval. I
El Other(describe):
a
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Commonwealth of Massachusetts
Title 5 Official Inspection Form 1
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Oldham Road
Property Address
John Reen
Owner Owner's Name
information is required for every Osterville MA 02655 10-4-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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Approximate age of all components, date installed (if known) and source of information:
2009 Permit # 2009 - 158_
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Were sewage odors detected when arriving at the site? 0 Yes ® No t
Building Sewer(locate on site plan):
Depth below grade: 40feet
i Material of construction:
n
1 ❑cast iron ® 40 PVC ❑other(explain):
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Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Piping is 4" PVC SCH 40
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Septic Tank(locate on site plan):
Depth below grade: 28
feet i
I Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
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If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
_ Dimensions: 1500 Gal, Precast H-10
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Sludge depth:
15irts.doc-rev 6118 Tlde 5 0fBclal Inspection Form:Subsurface Sewage oispasal System-Page 9 of V i
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Oct, 10 2016 22:34 Jim The Inspector .Man 50,85349919 page 10
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Commonwealth of Massachusetts
Title 5 Official Inspection Form F
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
64 Oldham Road
Property Address
John Reen
i' Owner Owner's Name
information is required for every Osterville MA 02655 10-4-16
t
page. CilylTown• . State Zip Code Date of Inspection
D. System Information (cont.) 1
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
8„
Distance from top of scum to top of outlet tee or baffle
t
Distance from bottom of scum to bottom of outlet tee or baffle
181,
i How were dimensions determined? Asbilf- Plan -Tape
'i Sludge .Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
1' liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank at 28"below grade. In and out let tee's. No sign of leak age of over
loading.
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Grease Trap (locate on site plan):
Depth below grade:
I feet
1, Material of construction:
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❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): i
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,
Dimensions:
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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
F
Date.of last pumping: Date
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15ins.doc•rev 6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
f Oct .10 2016 22:35 Jim The Inspector Man 5085349919 page 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Oldham Road
Property Address
John Reen f
Owner Owner's Name
information is "
required for every Osteryille MA 02655 10-4-16
page. City/Town State Zip Code Date of Inspection i
D. System Information (cont.) f
i
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1
1
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): "
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Dimensions: j
Capacity: gallons
f 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.):
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1 "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
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15ins.doc•rev.6116 Tille 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
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Oct.. 10 2016 22:35 Jim The Inspector Man 5085349919 page 12 i
Commonwealth of Massachusetts i
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Oldham Road
Property Address
John Reen
Owner Owner's Name
informatifor every on is
required Osterville MA 02655 10-4-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan): k
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Depth of liquid level above outlet invert
t �
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x 16"-32" below grade w/cover at 12" . Box is clean and solid w/4 lines out. No sign
of over loading or solid carry over.
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Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
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Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
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•If-pumps or alarms are not in working order, system is a conditional pass, t
Soil Absorption System (SAS) (locate on site plan,excavation not required):
If SAS not located, explain why:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
64 Oldham Road
Property Address I
John Reen '
Owner Owner's Name i
information is 9
required for every Osterville MA 02655 10-4-16 }
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
i ® leaching chambers number: 16
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❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
iY I
❑ overflow cesspool number: ,
0 innovative/alternative system
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Type/name of technology:
1
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is 16 Biodiffuser chamber stone less chambers.Ck D Box and camera out line's. `
Chamber's are clean and dry.
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4
S,
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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
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Indication of groundwater inflow ❑ Yes ❑ No f
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i
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Oct. 10 2016 22:35 Jim The Inspector Man 5085349919 page 14
Commonwealth of Massachusetts
_ Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Oldham Road
ii Property Address
i John Reen
Owner Owner's Name `
information is Osterville MA 02655 10-4-16 t
required for every
page. City/Tawn 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.):
f
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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.):
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Oct. 10 2016 22:35 Jim The Inspector Man 5085349919 page 15 �
Commonwealth of Massachusetts
Title 5 Official Inspection Form
R Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -
64 Oldham Road i
F
Property Address
r John Reen
Owner Owner's Name
information is Osterville MA 02655 10-4=16
required for every `
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:
t
Z hand-sketch in the area below
❑ drawing attached separately
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3_ 1.5' 01
C;3 �)9-19 t g
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Oct,10 2016 22:35 Jim -The Inspector Man 5085349919 page 16
Commonwealth of Massachusetts
Title 5 Official Inspection Fora'
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�? I
64 Oldham Road i
Property Address
John.Reen
Owner Owner's Name
information is required for every Ostervllle MA 02655 10-4-16
page. City/Town State Zip Code Date of Inspection
I D. System Information (cunt.)
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I Site Exam:
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❑ Check Slope j
❑ Surface water
❑ Check cellar
❑ Shallow wells
IA/0
10'+
Estimated depth to high ground water: feet
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Please indicate all methods used to determine the high ground water elevation:
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i Obtained from system design plans on record
If checked, date of design plan reviewed: 5-22-09
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
1
❑ Checked with local Board of Health -explain:
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❑ Checked with local excavators, installers-(attach documentation) I
Accessed USGS database-explain:
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I You,must describe how you established the high ground water elevation: '.
T.H.on Design plan 5-22-09 10'+. No G.W. Bottom of chamber's at 5'+ above T.H. Depth..
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Before filing this Inspection Report,please see Report Completeness Checklist on next page. t
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Commonwealth of Massachusetts
Title 5 Official Inspection Form _
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
64 Oldham Road
i. Property Address
John Reen
Owner Owner's Name i
information is Osterville MA 02655 10-4-16
required for every Page City/Town Slate Zip Code Date of Inspection i
E. Report Completeness Checklist E
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® 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
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t51ns.doc•rev.6116 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17
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TOWN OF BARNSTABLE
LOCATION 4 a SEWAGE# 2001 —
VILLAGE 6,sien 16 ASSESSOR'S MAP&PARCEL /o?U — /07
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY _ /6 6V
LEACHING FACILITY-(type) (� /�� r!a� �o A.P-P(size) I i.Z K �2 C.®
NO.OF BEDROOMS _3
OWNER co\n v-,
PERMIT DATE: (0 m Ll - ZAOA{ COMPLIANCE DATE: (0 4' ' 1000(
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility No Z1 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 1. Ap P S-t2 S
j�rN r%w�-�s'� -�wonw
y
S
�/ J J TOWN OFBARNSTABLE L�
LOCATION (0 1 OI C�'I QM I` - SEWAGE #
VILLAGE 0 S1 Irv,14. ASSESSOR'S MAP & LOT 4
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) �oX6~ l �T (size)
` NO.OF BEDROOMS 3
BUILDER OR OWNER CULT �12t1
PERMITDATE: 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 leachi facility) JJ Feet
Furnished by TnS�O0."T' -T. Fo�G
r 3► aye 3
a 36 30
311 3a y
y -3-36 3�
•LOCAT low SEWAGE PERMIT NO.
VILLAGE
4 S f F� �/ l ,l� M ,�►
INSTALLER'S NAME & ADDRESS
DF tir i S POP-7 N 4 /Y/7v,P�'
BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
3`rt
f
31
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1.
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J
TOWN OF BARNS TABLE
LOCA'f'fb _G l 01_d6vv-� Rc SEWAGE #
PILLAGE O s "er v
ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. k t� A 01 nn eS
CO SEPTIC TANK CAPACITY l ODD
LEACHING FACILITY: (type) 7 (size) X L
NO.OF BEDROOMS 3
BUILDER OR OWNER 1IVAA 1 1 Sker
PERMITDATE: 'I ///! 7 l COMPLIANCE DATE: �l
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
3ACk
Al -
na- 34 c� s
A 31
3
a 133 - 3a;�°..`.
AH 33�°
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye
\ 01ppricatiou for Dizpogal 6r5tem Con.5truction permit
1 Application for a Permit to Construct( ) Repair('X grade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. (v LI OI a %own (LOP-CA Owner's Name,Address,and Tel.No. T aN (LU-44
Obi Gai --A le 63 C1,earmr?f—iC/ R`^�
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. 1--)1/r rf t4j Designer's Name,Address and Tel.No. ITpj-X ro-fl Nr Y
PO d�K ?�3 -7,7 f,�Sb 2 aZ�YLv�u sr"
Ccf,rC4 -life l i
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size 17! Z 2k sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided ] gpd
Plan Date W Number of sheets Revision Date
Title Li
Size of Septic Tank LsL-) ti Type of S.A.S. 13 D
Description of Soil c _Q+ �ll�{-((�
Nature 5 Repairs or when applicable)
Date last inspected: ' aq!� 7
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 Vf1jealth.
rN Signed ® Date (D L� Zbl'7
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. < Date Issued
AN
wool
No. � ► ;� ..+ - fr ..Fee
THE CO OF MASSACHUSETTSf e Entered in computer:
PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS 'Ye
=f 1.
a
.s -Application for m ogal *pgtem Co'n5truction Permit
�( Application for a Permit to Construct( ) Repair(/Pradeg ( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. 01 VI A w, R-0 0,N Owner's Name,Address,and Tel.No.
O S i G2v.��Q
Assessor's Map/Parcel14.
�t
r• 'a :. Installer's Name,Address,and Tel.No. 4w 410t—h(fie E-"?�!Leaf iej Designer's Name,Address and Tel.No. �i'�>C r.-A W y C�
4 '
t>0 3
C_cJ�, 2r r c 7"7( -7_)7?)Z
Type of Building: 3 }
4, Dwelling No.of Bedrooms Lot Size ��{ 2 Z� sq.ft. Garbage Grinder ( ) .
Other Type of Building S, No.of Persons Showers( ) Cafeteria( )
I Other Fixtures
;t
' - Design Flow{min.required) �j gpd Design flow provided O gpd
to
f Plan Date O� Number of sheets 1 Revision Date
*w. Title (0 0
,. Size of Septic Tank "°.(��� C/YL� Type of S.A.S. , k-jk-j cS_� (('0o 't j 1)
Description of Soil cysac IQ C.� t CD,!
( -
Nature of Repairs or Alterations(Answer when applicable) 0" E
Date last inspected: Sao!O ?
Agreement: .,f
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 gfTiealth.
Signed 0, _ 4 p Date to
Application Approved by /, p �. Date
Application Disapproved by: l Date
for the following reasons `
�"" ,
Permit No. "' o Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
1
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewa a Disposal System Constructed ( ) Repaired (�) Upgraded ( )
Abandoned( )by
at (o L� D�� 1n✓���.+ R-'� h� f j�/.h lk.i has been constructed in accordance
with the provisions of Title 5 and the fo Disposal System Construction Permit No.. dated
Installer C�,:)t 1-LC J,- .) t•) L L(..,_ Designer ~t w r N 4A
#bedrooms 7) Approved design flov6\ gpd
The issuance of thi permit shall not be construed as a guarantee that the system wilt,flfuunct 1}as designed.
I!�
Date b� Inspector 11'A� 1/y-
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
` Digogal *pgtem Construction permit
Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon ( )
System located at (oL( ok,I(„ . M..•, fj�i-r.✓�A`1�.
P
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: Construction s be completed within three years of the date of this pe m E
Date roved/J A /� pP b Y , f�
1 �
Town of Barnstable
' Regulatory Services
• • antuvsTnsi.�, •.
Thomas F.Geiler,Director
Public Health Division
fa= ° Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer &:Desiener Certification Form
Date: 4 . OS Sewage.Permit# ZOOIT.- 1.TS Assessor's Map\Parcel /Lo /07
Designer:.g 5izoilAh A. W- rNF. Installer: �s����� Qube,►u�r,�cs
Address: Ua2.6, y... Address: iP o,, ram 7i6s
7:g �1OV�_ �Tr ��4NH15 LLN�tPVf��I'G
Qn b" 5!-o<y Ca was issued a:permit to install a
(date) ('installer)
septic system at 6V D/clhoo, based on a design drawn by
(address)
S�c.or�d. A.._Ili L&ft _ P.e- dated
(designer)
_ I certify_that the septic system referenced above was.installed substantially according to
the design,,which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that he.septic system.referenced above was installed with major changes (i.e.
greater than 10'"lateral relocation of the+SAS or any vertical relocation of any component
of the septic-system)-but in accordance with.State & Local—Regulations. Plan revision or
certified as-built by designer to follow.
yw.
(Installer's Si e)
No,3WS
� lBTE
sAt.
*esigner's Signature) (Affix Designer's Stamp Here)
PLEASE._ RETURN TO BARNSTA;BLE 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/Desiper Certification Form 3-26-04.doc ��200of—0 6-4
rrcaarauon or rians ana avectncanons
The plans and specifications for every on-site system shall be prepared as follows: n
(I) -Every system shall be designedyby a Massachusetts Registered Professional Engineer v
or a Massachusetts Registered Sanitarian provided that such Sanitarian shall not design a
system.designed to discharge more than 2,000 gallons per day pursuant to 310 CMR 15.203.
Any other agent of the owner_ may prepare-plans for the repair of a system.designed to
discharge not more than than ZOWgagtons per day pursuant to 310 CMR 15.203 provided
they are reviewed by a Massachusetts Registered Sanitarian and approved by the approving D-
authority-,
— (2) Every plan submitted for approval must be dated and bear the stamp g and signature of
00 designer,
(3) . Every plan-for a new system or plan for the upgrade or expansion of an existing system
which requires a variance to a property line setback distance,must.also reference a plan O
which bears the stamp and signature of a Massachusetts. Licensed Land Surveyor in �1
accordance with M.G.L. e: 1I2, § 811); Q
(4) Every plan for a system shall be of suitable scale(one inch=40 feet or fewer for plot
plans and one inch = 20 feet or fewer for details of system components) and shall include
depiction of:
(a) the legal boundaries of the'facility to be served:
(b) the holder and location of any easements appurtenant to or which could impact the
system;
(c) the location of the all dwelling(s)or buildings)existing and proposed on the facility
and identification of those to be served by the system;
(d) -the'location of existing or proposed impervious areas,.including driveways and
parking areas;
(e) location and dimensions of the system (including reserve area);
(f) system design calculations,including design daily sewage flow, septic tank capacity
(required and-provided); soil absorption system capacity (required and'provided); and
whether system is designed for garbage grinder;
(g) North arrow and existing and proposed contours;
(h) location and log of deep observation hole tests including the date of test, existing
glade elevations marked on each test, and the names of the representative of the
approving authority and soil evaluator;
(i) location and results of percolation tests including the sate of test and the names of
-the representative`of the approving authority and soil evaluator,
i) name-and certification number of the Soil Evaluator of record;
(k) location of every water supply,public and private,
1. within 400 feet of the proposed system location in the case of surface water
supplies-and gravel packed public water supply wells,..
2. within 250 feet of the proposed system location in the case;of tubular public
water supply wells, and
3. within. 150 feet of the .proposed system location in the case of private water
Supply wes;
— (1) location of any surface waters of the Commonwealth, rivers, bordering vegetated
wetlands, salt marshes, inland or coastal banks, regulatory floodway, velocity zone,
surface water supplies,tributaries to surface water supplies;certified vernal pools,private.
water supplies or suction lines, gravel packed or tubular public .water supply wells,
subsurface drains, leaching catch basins, or dry wells; and the location of any nitrogen
sensitive.area identified'in 310 CMR 15.215 within which portions of the proposed
system are located.
(m) location of water lines and other subsurface utilities on the facility;,
(n) observed and adjusted ground-water elevation in the vicinity of the system;
—( ) a complete profile of the system;
(p) a note on the plan listing all variances to the provisions of 310 CMR 15.000 sought
in conjunction with the plan;
(q) the'location and elevation of one benchmark within 50 to 75 feet of the facility
which is not subject to d;slocation or loss during construction on the facility;
(r) when dosing is'proposed, complete design and specification of the dosing system
proposed including but not limited to dosing chamber capacity (required and provided),
pump curves and specifications, number of dosing cycles and depth.per cycle;
(s) when a Recirculating Sand Filter or equivalent alternative technology is required or
proposed,a complete plan and specification for the system,including a hydraulic profile;
(t) a locus plan,to show the location of the facility including the nearest existing street;
(u) the street number and lot number, if any, of the facility; and
(v) the materials of construction and the specifications of the system.
i
i TRANS.NO::
CITY/TONVN:
APPLICANT: Ca,
ADDRESS: 6ef
DESIGN FLOW: C) gpd
REVIEWED-BY: -n DATE:
N/A OK NO
Legal boundaries denoted [310 CMR 15220(4)(a}]
Street,Lot,tax parcel number and lot number noted on.plan[310
CMR.15220(4)(u)J
Locus Provided[310 CMR.IS2204(t)]...
Plan proper scale?(1"=40'for plot plans,l"=20'ar fewer for
.. components) [310 CMR 15220(4)]
Easements shown[310 CMR 15.220(4)(b)]
System located totally on lot served[310 CMR.15.405(1}(a)for
upgrades]- i not, a variance is required [310:CMR 15.4.12(4)]
Location of impervious surfaces(driveways,parking areas etc).
[310 CMR 15220(4)(d)J
Location all buildings existing and proposed 310 CMR
.1.5220.(4)(c)J
Location and dimensions of system components and reserve areas.
[3.10 CMR 15220(4)(e)J
System Calculations [310 CMR- 15220(4)(f)]
daily flow
septic tank capacity(required and provided)
soil absorption system(required and provided)'
whether system designed for garbage grinder
North arrow [310 CMR 15220(4)(g)]
Existing and proposed contours[310 CMR 15.220(4)(g)].
Location and log-of deep observation holes(existing grade el.on
each test) [310 CMR 15.220(4)(h)]
Names of soil evaluator and BOH representative[310 CMR
15220(4)(h) and(i)J f
Location and date of percolation tests(performed at proper
elevation?) [310 CMR 15220(4)(i)] "
Percolation test results match loading rate? [310 CMR 15.2421
Certification statement by Soil Evaluator[310 CMR 15220(4)6)]
Observed and Adjusted groundwater(method for adjustment
given or indicated) [310 CMR 15.103(3) and 310 CMR
15.220(4-)(n)J
Address Sheet 1.of 7
i
N/A
- OK NO
Location of every water supply,public and private,[310 CMR
15.220(4)(k)] L
within 400 feet of the proposed system location m the case
of surface water supplies and gravel packed public water supply
within 250 feet of the proposed system location in the case
within 150 feet of the proposed system location in the case
of private water supply wells.' t/
Location of all surface waters and wetlands located up to 100 ft.
beyond setbacks listed in310 CMR 15.211 and any catch basins
located within 50 ft. [3.10 CMR.15.220(4)0)]
Water lines and other subsurface utilities located[310 CMR
15.220(4)(m)] (if water line cross.see 310 CMR 152110)[11) v
Profile of system showing invert elevations of all system
components and the bottom of the SAS [310 CMR15.220(4)(o)J .
Stamp of designer.[310 CMR 15.220(1)and 310 CMR 15.220(2)]
Stamp of Registered Land.Surveyor(required if construction
activities within-5 ft. of lot.line)::[310 CMR 15.220(3)]
Test Holes adequate(two in each of the primary and reserve
unless trenches As permitted in 310.CMR 15.102(2)or as
approved for an u -
PP upgrade under I;UA at 310 CMR 15:405(1)(k)]
Test hole adequate to.demonstrate*four feet of suitable material? .
[310 CMR 15.103(4)] t�'
Test Holes.adequate to-confirm adequate groundwater separation?
[310 CMR 15.103(3)]
Benchmark within 50-75'of system[310 CMR 15.220(4)( )
Materials specifications noted?-[various sections of 310 CMR
15.000)
System components not>36" deep(unless Local Upgrade
jApproval orLUA requested):[310 CMR 15.405(l(b)J
Address Sheet 2 of 7
NA
/ OK NO
_ __ -s-.-,��.s—'�,.�'.�" „$„�Y'% -- '..."fin .,,.� ,a-.�..�.-,; ��,'x���x. �-..�.F �.,,�• 9 .
Size OK? [310 CMR 15.223(1)]
Inlet tee located ten inches below flow line[310 CMR 15.227(6)]
Outlet tee 14" of 14"+5"per foot for increase ft depth,[310 CMR
15.227(6)]
Outlet tee with gas baffle or approved filter[310 CMR 15.227(4)]
Note regarding installation on stable compacted base[310 CMR
15.228(1)]
Separation between inlet and outlet tees(no less than liquid
depth) [310 CMR 15.227(2)]
Inlet/Outlet elevations at least 12" above high groundwater-
(except as described 310 CMR 15-.227(5)):or permitted for
upgrades under LUA[310 CMR 15.405(1)(k)]
Minimum:cover 9" (Tanks buried more than 9"must have risers
on all openings and on the d-box) [310 CMR 15.2228(1)and-310
CMR 15.232(3)(fl]
Three access covers (inlet and outlet must be 20" or greater)-.
middle access at least 8"(by 7/07) [310 CMR 15.2N(2)]
Access to within 6 " of grade -one port for systemsc1000gpd,
two for.systems>1000 gpd[310 CMR 15M8(2)]M.at=grade covers secured to unauthorized access? [31 Q CMR
15.228(2)]
> 10 ft from building foundation[310 CMR 15.21.1(1)1
Buoyancy calculation R `uired/Done[310 CUR 15.221(8)].,
H720 Where appropriate? [310 CMR 15.226(3)]..
Setbacks from resources [310 CMR 15.2111
Required when other than single-family dwelling of.flow>1000
1
gpd [310 CMR 15.223(1)(b)]
First compartment 2.00%daily flow; Second_compartment 100°fo
daily flow [310 CMR 15.224(2) and(3)] _
"U"pipe through or overbaffie,.outlet of each compartment with
gas baffle or approved filter[310 CMR 15.224(4)]
•
Address 6 0.166te,,4
Sheet 3 of 7
I
N/A OK NO
Located at least ten feet from any water line? [310 CMR
15.222(2)] � (�
Disposal piping at least 18"below water line when water and
( _
sewer cross, see 310 CMR 15.211 1 1
Cleanouts required/provided? [310 CUR 15.222(8)]
Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)]
Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable r �
[310 CMR 15.222(6)] E�
Proper pitch on all runs? (.005 within gravity-distributed trenches
and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)]
Siphon problem/(leachfield below pump chamber)
Endcaps or vent manifold specified?
Size and orientation
n ntation of discharge
e holes specified?
fied?
(not small
er
than 3/8" not larger.than 5/8") [310 CMR 15.25'1(8)and 310.
CMR 15.252(2)(h)] -
Materials specified (310 CMR 15:251(5)specifies various pipe r
types allowed) -
Stable compacted base[310 CMR 15.221'(2) and 310 CMR
Splash plafe or baffle tee requiied on inletl provided?(when -
pressure sewer to d-box or steep pitch of gravity sewer)[310
-
CUR 15.323(3)(a)]
� .
Riser if de6lier than 9" [310 CMR 15.232(3)(01
Inside minimum dimension 12" [310 CMR 15.232(2)(b)]'
Minimum,sump 6" [310 CMR15.232(3)(e)]
Watertight cover if<2000gpd);waterproof manhole if>2000gpd
[310 CMR 15.232(3)(d)]
Capacity(emergency storage above working--design flow)? [310
CMR 231(2)J
Proper setbacks [310 CMR 15.211 (same as septic tanks)]
Watertight 20-in minium access manhole at least 20"MUST BE
TO GRADE[310 CMR 15.231(5)] - L/
Service components accessible(not too deep with piping, I
disconnects accessible)-
Alarm floats_-alarm on circuit separate from pumps specified?
Exceeds two units must have two pumps operating in lead-lag
mode. [310 CMR 15.231(6) and(8)]
Stable Compacted Base [310 CMR 15.221(2)] j
. Buoyancy calculations needed?Provided? [310 CMR 15.221(8)J
Address f`l 6/d A, Sheet 4 of 7
. - I
N/A OK NO
Calculations correct?
4 feet of naturally occurring material demonstrated? [310 CMR
15.240(1)]
Required separation to groundwater?[310 CMR 15.212)]
Aggregate specified as double washed[310 CMR 15.247(2)]
System Venting required/provided? (system under driveway or-
>36" deep) [310 CMR 15.241]
Inspection ports specified and within 3"final grade? [310 CMR
15.240(13)]
Breakout requirements met? (No violation of breakout elevation
within 15 ft of SAS unless barrier) [310 CMR 15.211(l)[4] and
Guidance Document]
_...,S -,..s? __._.......-.ems_._ .-.,a-_—.��x,......_._.y��._ar.=� ��rt-�-.��..��-+ti4c-Y�"•--:. ,�-na' �_s.'^-'� -�.-1-A`�'�_
Chambers and Gal: in trench configuration supplied with inlet
every 20 ft. [310 CMR 15.253(6)]
Each structure with one inspection manhole(if>2000 gpd must'
be to grade). [3.10 CMR 15.253(2)] S/
Aggregate 1'.minimum-4'maximum. [310 CMR.15.253(1)(b)] _
2'.sidewall credit maxirnum.[310.CMR 15 253(1)(a)].
In bed configuration, inlet every 40 sq.-ft. [310 CMR.15.253(6)]
width r minimum 3`maximum[310 CMR=15.251(1)(b)J
100 feet-'maximum length.[310 CMR 15.251(1)(a)j • .. ., . . . _ .
Minimum separation 2x effective depth or width whichever
greater(3x if reserve between trenches).[3 10 C.MR.251(1)(d)]
Situated along.contours[310 MR 15:251Q)] :..
Breakout OK? [310 CUR 15 211(1)[4] and Guidance Document]
. "�_--�.._.".�.+�.;ar..-. ._.s..+a+-gaf-�.u.r.'.+,*w.c-.��..ar�.r. ac._.. .r-e._._..'Y.A_ -+�.�`^--..��L.-a���?..��, ...�.. Fzkd-°'u�u. :..�--^•.-^- n--...�...}
minimum 2 distribution lines[310 CMR 15.252(2)(a)]
Maximum separation between lines 6'[310 CM R15.252(2)(d)]
Maximum separation betweenjines and outside of bed 4'[310
CMR 15.252(2)(e)J: :
Aggregate depth below discharge pipes 6".minimum, 12"
maximum. [310 CMR 15.252(2)(g)] C►w„�V,�.�s�}
Separation between beds 10'minimum [310 CMR 15.252(2)(0]
Bottom area used in calculations only[310 CMR 15.252(2)(i)]
Address
Sheet 5 of 7
I
,
- N/A OK NO
t�
Pressure Dosed System ? Provided pump and piping
calculations as required[310 CMR 15.220(4)(r)]
Pressure dosing required on all systems>2000gpd or altelm ative
systems under remedial approval [310 CMR 15.254(2)and I/A
Remedial Use Approvals]
If used in gravelless system-make sure jet is directed as -not-
to.
scour soil interface[Guidance Document]
Inspections once per year(systems<2000 gpd)or quarterly -
(>2000gpd) good to note on plan[310 CUR 15.254 2 d `
COIistruction in fill -Did the plan specify that the fill shall meet f
the specification of 310 CMR 15.255(3)? V
Impervious barrier and/or retaining wall? [Guidance Document]
Impervious barrier installation must be supervised by
designer [310 CUR 15.255(2)(b)] .
Retaining wall must be designed by Registered,Professional -
Engineer [310 CMR 15:255(2)(a)J
Side slope not exceed 3:1 ? [310 CMR 15.255(211.
Breakout requirements met? [310 CMR 15.252(2)and
Guidance Document]
At least 5 ft.from impervious barrier to edge of SAS.: (1.0$.
recommended) [310 CMR 15:255.(2)(e)]
Check DEP Approval letters for credits and design.conditions
1
If used with pressure dosing do not allow pressure discharge
to scour soil interface
ternaeexSy�stem #Ads ova �ette s
Was.DEP Approval Letter provided and/or have you.
reviewed.the letter for conditions?
Is the technology being properly applied/and does;it meet all:
DEP Approval Conditions? °'
Is there a note on the plan regarding the requirement for
Perpetual maintenance agreement?
Any alarms involved on separate circuits
Did the applicant submit an operation and maintenance
manual?.
Has ap licant submitted a copy of a maintenance
-,.-�.-mr-`---s „� :�M s� �i��G�LL_,,,s��.,.�-b'...—'use. ��.ar'�'•"�3�.f�cr-. ,-�,. -- r-�.c-,,'"3�-.-`Are.the variances listed on the plan? [310 CUR 15.220
(4)( )]
RLS Stamp necessary on plan if a component is within five
feet of property line [310 CMR 15.412(4)]
New construction or increased flow proposed-[Refer to 310
CM '15.414]
Address_ C'se/ b I cl
Sheet.6 of 7
�D�r1Z3r1Z3. �31 SI����=3'P�IS�" � �-r :. _"_ �-�'�� =-t"•1.�,_ r�N/A �� OK N
Is the system in a Designated Nitrogen Sensitive Area(Zone 11 for
a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and
310 CMR 15.216-also refer to Policy regarding upgrades of such V --
existing systems]
Is the system proposed on the same lot as served by private well ?
[310 CMR 15.214(2)]
Are the nitrogen loads proposed in compliance? [310 CMR
15.216(1)]
cdaneau a
Pumping to septic tank? [310 CMR 15.229]
Shared System[310 CMR 15.290].
-Address t/ Sheet 7 of 7
i
Town of;Barnstable? P#
Department of Regulatory Services
seantar�etE Public Health Division Date z 7
03� �e� 200 Main Street,.Hyannis MA 02601,
rfu ,t• -
Date Scheduled. Time Fee Pd. a r
Soil Suitability Assessment for Sewage Disposal
Performed By: �rG :W t "',�ev1 . C Witnessed By: � s �
I:,OCA'T�jUN•& CENERAL.:INT�'QTNtEf, 0:1� f Location Address Owner's Name ee A �t1A Dor
eAtv
Address `I t C(hU, t,cV
Assessor's Map/Parcel- 2 -- Jo-7 Engineer's Name S f r v-z 0 I
}.Jt'r�rr -'A:leya.
NEW CONSTRUCTION REPAIR Telephone# i�,r•.,. 1 t �.• ,,c= + L '�; .
Land Use IRc.^,t cke,,,d}el Slopes(%) Surface Stones V1 n!'\ `
Distances from: Open Water Body ft .Possible Wet Area ft Drinking Water Well ft
Drainage Way ft .Property Line ft. Other ft
SKETCH:(Street name,dimensions of lot,exact locations.of test holes&pert tests,locate wetlands in proximity to holes). '
.� #z
ti
a
Parent material(geologic) ( l ee m-;,l (�,. 1LLt.,..,a.t�... Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: Weeping from PIt Pace .
Estimated Seasonal High Groundwater
.. DEURMINAT1ON OR StASQNAL RICH WA I-"-T"'--V
Method Used:
Depth Observed standing in°obs.hole: In. Depth to Boil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft•
Index.Well# Reading Date: Index Well level ;� Adj..faetor ,,� Adj,Groundwater Level
C()I,ATION,TE ST
Observation .
Hole# 2 Time at 9"
Depth of Perc SG Time at 6"
Start Pre-soak Time @ //'2a Time(9"•6")
End Pre-soak lr;ZS •` `
Rate Min./Inch 7.c
Site Suitability Assessment: Site Passed 1100 Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back------:----
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division.at.least.one(1) week prior to beginning.
Q:\SEPTIC\PERCFORM.DOC. . -
DEEP OBSERVA11ON ROLE LOG Tole#
Depth from Soil Horizon Soil Texture Soil Color .
Surface(in.) Soil Other
(USDA) (Mansell) Mottling (Structure,Stones,Boulders.
Consistenc %Gravel
6 t 5� A I.o t^� I O Y K 316
h
Jcrnu� 400 M l0 yl?
DEPP`OBSEkVAh.6N HOLE.LOG fTnle#
De
pth tli fro
m
Soil Horizon
Soil Texture Soil Color Soil Other
Surface(in.) (USDA)'
(Munsell) Mottling (Structure,Stones,Boulders.
onsistenc %Gravel
3/z
Ea nary 4 aan? f0 S�'/2 1///
/0 'Ile :'//,
SN -, o / nm«t-- Co.Q.s�
Z CZ
i
DEEP"ODSERVATION HOLE I OG
Depth from HQIe#
P Soil Horizon Soil Texture Soil Color Soil . Other
Surface(in.) (USDA)
(Munsell) . Mottling (Structure,Stones,Boulders.
Consistency.%Gravel
DLEP'O$SERVATION HOLE.LOG Hole
Depth from Soil Horizon: Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell
Mottling (Structure,Stones,Boulders.
on,isten o Gravel)
F1'tiod Insurance Rate Man•
Above 500 year flood boundary No Yes
Within 500 year boundary No,� Yes
Within 100 year flood boundary No x Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Cecti— fication
I certify that on A�iJl /"Is (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above.analysis.,was performed by me.consistentwith
the required training,_expertise and experience described in 310 CMR 15.017.
Signature'`� �' Date .S12 7/0-r
d.\SEPTIC\PERCFORM.DOC
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP Z'b.,�..,.
PARCEL
LOT
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 64 Oldham Road
Osterville, MA 02655 RECEIVED
Owner's Name: Curt Bletzer
Owner's Address: DEC 2003
Date of Inspection: November 24, 2003 TOWN OF BARNSTABLE
Name of Inspector: (Please Print) James M. Ford HEALTH DEPT.
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
" \ CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the 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 `
Need F rther Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 07 Date: December 7, 2003
The system inspector shall submt,a copy of this inspection report to the Approving Authority(Board of.Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 64 Oldham Road
Osterville, MA
Owner: Curt Bletzer
Date of Inspection: November 24, 2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. „
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally '
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 64 Oldham Road
Osterville, AM
Owner: Curt Bletzer
Date of Inspection: November 24, 2003
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:
c
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 I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free)from pollution from that.facilityand
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 64 Oldham Road
Osterville, AM
Owner: Curt Bletzer
Date of Inspection: November 24, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due tp an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
_ ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high groundwater elevation.
_ ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either`yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the-system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped
Zone 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 64 Oldham Road
Osterville, MA
Owner: Curt Bletzer
Date of Inspection: November 24, 2003
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner, occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for,signs of break out?
✓ _ Were all system components,excluding the SAS, located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge.and depth of scum ?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The,size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ Existing information. For example, a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
I ,
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 64 Oldham Road
Osterville, AM
Owner: Curt Bletzer
Date of Inspection: November 24, 2003
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: 0
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(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIALANDUSTRIAL
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(d6cribe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection (yes or no):
If yes,volume pumped: Qallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, date installed(if known)and source of information:
Apr. 4177-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 64 Oldham Road
Osterville, MA
Owner: Curt Bletzer
Date of Inspection: November 24, 2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage, etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 16"
Material of construction: ✓ 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 gal.
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: 29"
Scum thickness: 6"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
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.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 64 Oldham Road
Osterville, MA
Owner: Curt Bletzer
Date of Inspection: November 24, 2003
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: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: --
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of
leakage into or out.ofbox,etc.):
The D-box was broken down structurally. A new D-box was installed(Permit No. 2003-590)
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
1
8 .
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 64 Oldham Road
Osterville, M4
Owner: Curt Bletzer
Date of Inspection: November 24, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1 - 6'x 6'(1000 gal.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.):
The leach pit had 4'ofwater on the bottom. The scum line was approximately at the same level. There did not appear to be any
signs of failure. The bottom to grade was 8.0'.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
J
9
i
Page 10 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 64 Oldham Road
Osterville, MA
Owner: Curt Bletzer
Date of Inspection: November 24, 2003
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.
a 30� 30
3 31 3a y
y
10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 64 Oldham Road
Osterville,AM
Owner: - Curt Bletzer
Date of Inspection: November 24, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30 +/- feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map,the maps were showing approximately
30'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
i
11
No. 200 3 V Fee �v
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYication for Migw6ar *pgterd Con0tructiott Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. 6 Y 0/6 1tv', R�- Owner's Name,Address and
Tel.No.
Assessor's Map/Parcel 0 STe(V
161
Installer's Name,Address,and Tel.No. LJJr Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 1J' (SOX (e-M t f
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this Board of He th.
Signed Date
Application Approved by .S• Date 2
Application Disapprove or the following reasons
Permit No. Date Issued Z
No. 2�0 3 '5 / U Fee f e)
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
application for Migpo.5al 6potem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
_ Location Address or Lot No 7C ^ 1 ' f Owner's Name,Address and Tel.No.
Olcln� Rc'.
,ram- 1 r
Assessor's Map/Parcel S�"" V�� d o C� (J'� t �Z C(�+
Installer's Name,Address,and Tel.No. `� "l.t e; - f '-i r— Designer's Name,Address and Tel.No.
�1 r"I (�
CJ�eUn r • (�v V/YM
U S
Type of Building: ,
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder,( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title :i. 4.,.
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 'J' aQX (9-n A-f
v op
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued this Board of He th.
Signed Date I
Application Approved by -� ® Date_
Application,Disapprove for the following reasons
Permit No. *2 o U fir- 5 U Date Issued 2 Z u
--------------------------------------- -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS �-
Certificate of (Compliance
THIS IS TO CERTIFY,that the On site Sewage Disposal System Constructed( )Repaired( )Upgraded( )
�7 .r l3 s
Abandoned( )by. G�r Un fA u S
at G`� ' 0'�-� /�n�' " R : �. CI S%6��Il '
' has been constructed In ac ordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 U o 3- S 76dated 12 2 0 3
Installer Designer
The issuance of this pei7nit sLll not be construed as a guarantee that the syste w' {c i s e igned. .
Date 1316-3 Inspector ..�'
q i
No. �UQ� ; /G --------------------------Fee
THE COMMONWEALTH OF MASSACHUSETTS �OX ��PA,
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lwi.�pogal *pOtem,Congtruction Permit
Permission is herebyAgranted to,Cons /ct( )Repair(�Upgrade.(« t Bandon( )
System located at �� / r0� tY1"/-1�n^ Ri Oei�
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
f comply with Title 5 and the following local provisions or special conditions.
Provided:Constructi n st be completed within three years of the date of this permit.
Date:_ 22 a Approved by
f
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of Environmental ProtectionVj
One Winter Street, Boston MA o2loB (617)2925500
T
1 FO
T� Oc I999 TRi D COXE
/Secretary
16.
ARGEO PAUL CELLUCCI DAV�I, B.STRUHS
Governor Tp ommissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM , P
PART A
CERTIFICATION
Property Address: 64 Oldham Road, Osterville, MA Name of Owner: Eynn Fisher
Address of Owner: P.O. Box 3297
Date of Inspection: September 27, 1999 Waquoit, MA 02536
Name of Inspector: (Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map:
Telephone Number: (508)862-9400 • Parcel.
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes b
Needs Further Eval ti n By the Local Approving Authority 4
ails - -
Inspector's Signature: Date: September 28, 1999
The System Inspector shall submQa copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS .
revised 9/2/98 Page 1ofII
Primed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: ` 64 Oldham Road, Osterville, MA
Owner: .��r.•r Lynn Fisher
Date of Inspection: September 27, 1999
• t
INSPECTION SUMMARY: Check A, B, C, or D.
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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.
Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will'pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection.if(with approval of the Board of
Health)
broken pipe(s)are replaced
_ obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
revised 9/2/98 Page 2of11
�I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
' CERTIFICATION (continued)
Property.Address: 64 Oldham Road, Osterville, MA t
Owner: Lynn Fisher
Date of Inspection: September 27, 1999
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 the
public health, safety and 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 THE PUBLIC HEALTH AND
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. - - -
't. 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-AND SAFETY AND
THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is:.within 100:feet to;a surface water supply or
tributary to a surface water supply..
The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of"a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3ofII
r ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 64 Oldham Road, Osterville, MA
Owner: Lynn Fisher
Date of Inspection: September 27, 1999
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
_ I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than '/a day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.-
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or"No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 64 Oldham Road, Osterville, MA „ry
Owner: Lynn Fisher
Date of Inspection: September 27, 1999
<x .
Check if the following have been done: You must indicate either."Yes" or "No" as to each of the following:-, 2
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health.
✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection. r
✓ _ As built plans`'have been obtained and examined. Note if they are not available with N/A.
✓ The facility or dwelling was inspected for signs of sewage back-up.
✓ _ The system does not receive non,sanitary or industrial waste flow.:
✓ _ The site was inspected for signs of breakout.'
✓ _ All system components, excluding the Soil Absorption System,have been located on the site
✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic Tank was inspected for conditions of baffles
" or tees,material of construction;:dimensions,,depth of liquid,depth of sludge,.depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
✓ _ Existing information. For example,Plan at B.O.H.
✓ _ Determined in the field(if any of the failure criteria related to Pal C is at issue, approximation of distance is unacceptable)
[15.302(3)(b)l
✓ The facility owner(and occupants,if different from owner) were provided with information on the proper maintenance of
SubSurface Disposal Systems.
� 4
r, •
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 64 Oldham Road, Osterville, MA
Owner: Lynn Fisher
Date of Inspection: September 27, 1999
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 3
Total DESIGN flow n/a
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry(separate system) (yes or no): No ; If yes, separate inspection required
Laundry system inspected(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available(last two year's usage(gpd): 1998-57,000 gals.; 1997-21,OOO Qals.
Sump Pump(yes or no): No
Last date of occupancy: July '99
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: Qpd(Based on 15.203)
Basis of design flow
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
None on file-per treatment plant
System pumped as part of inspection(yes or no): No
If yes, volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all-components, date installed(if known)and source of.information: Apr. 04177-per as built card.
Sewage odors detected when arriving at the site: (yes or no) No
i
e 6 of 11
Pa
revised 9/2/98 s
SUBSURFACE-SEWAGE •DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) -
Property Address: 64 Oldham Road,'Osterville, MA
Owner: Lynn Fisher gv
Date of Inspection: September 27, 1999 ,_
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: —cast iron —40 PVC other(explain)
Distance from private water supply well or suction line t a
Diameter r _ ; �• F
Comments: (condition of joints, venting, evidence of leakage,etc.)
SEPTIC TANK: ✓ r Ah c , t
(locate on site plan)
Depth below grade: 16"
Material of construction: ✓concrete _metal Fiberglass _Polyethylene _other(explain)
If tank is metal,list age— Is age confirmed by Certificate of Compliance_(Yes/No) ,: ..
Dimensions: 8'6"x 4'10"x 5' (1000 gal.)
Sludge depth: 2„
Distance from top of sludge to bottom of outlet tee or:baffle 28" = , 'z
Scum thickness: 6" Y x w
Distance from top of scum to top of outlet tee or baffle +V., • s�=r}» ,
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were detemuned: Measuring stick '
a ..
Comments:
(recommendation for pumping,condition of inlet and'outleftees'or baffles, depth of liquid.level in relation to outlet invert, structural integrity,
evidence of leakage,etc.) Both of the baffles were present The liquid level was even with the outlet invert. Recommend pumping.
3
GREASE TRAP: None
(locate on site plan)
Depth below grade: s
Material of construction: concrete —metal Fiberglass Polyethylene _other(explain).-9.
Dimensions: . .
,c r
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: r " f
Comments: , fr
(recommendation for pumping condition of.inlet and outlet tees or baffles, depth of liquid level in relation to outlet'invert, structural integrity,
evidence of leakage etc.)
- ,v r. 6e, :- � •:... t �N.. . .::. F tom`
•
w
... .• - ..y ., r. a;. �,.-..<,a r�...._....,e.. .._. _.a a4c^. ,. *- �•.+Ja .'i+; .-..«�.-
revised 9/2/98 Page 7oftt
r a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 64 Oldham Road, Osterville, MA
Owner: Lynn Fisher
Date of Inspection: September 27, 1999 _
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or 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:
Alarm level: Alarm in working order: Yes No
- -
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: ✓
(locate on site plan)
Depth of liquid level above outlet invert: -- -
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) The D-box was located but
was not dug up. There were no signs of failure in the tank or the pit.
PUMP CHAMBER: None
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order: (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 64 Oldham Road, Osterville, MA
Owner: Lynn Fisher 1 i
Date of Inspection: September 27, 1999
SOIL ABSORPTION SYSTEM(SAS): ✓
v methods
' e• excavation not re required, location may be.a approximated b non-intrusive )
(locate on site plan, if possible; q y pp Y ,
If not located, explain:
Type
leaching pits,number: 1 -6'x 6'
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number, dimensions:
overflow cesspool,number: ,
Alternative system:
Name of Technology:
Comtttents:
(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.)
The pit had 2"of water on the bottom The bottom to grade was 8'. There were no signs of failure.
CESSPOOLS: None
(locate on site plan) n
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(cesspool must be pumped as part of inspection).
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY: None
(locate on site plan)
Materials of construction: _ Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc)
revised 9/2/98 Page 9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 64 Oldham Road, Osterville, MA
Owner: Lynn Fisher
Date of Inspection: September 27, 1999
Map:
Parcel.
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
3 �
AI - 3
JHU a
rya-
3
3a- 3�
AS- 3
(�
C�3 3a•
AH
3y 38
revised 9/2/98 Page 10of11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) M.
Property Address: 64 Oldham Road, Osterville, MA . '-
Owner: Lynn Fisher
Date of Inspection: September 27, 1999
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate. Deep
SITE EXAM Slope
Surface water
l Check Cellar '
Shallow wells
Estimated Depth to Groundwater 30+/- Feet "
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole,basement sump etc.)
Determined from local conditions
✓ Checked with local Board of Health ,
Checked FEMA Maps
Checked pumping records
Check local excavators,installers
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. (Must.be completed)
Using the Barnstable Water Contours map and the Topographic map, the maps were showing approximately 30' +/- to
groundwater at this site. Using the Cape Cod Commission Technical Bulletin, the high groundwater adjustment for this site
(SDW 253, Zone C, 8/99) was 5.5'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty x
or guarantee that the system will function properly in the future. There have been no warranties or guarantees; either expressed,
written or implied, relating to the system, the inspection and/or this report.
revised 9/2/98 Page 11of11 '
v 4a'
77
No........11-Q•......... Fix.. ......
THE COMMONWEALTH OF MASSACHUSETTS
�'D�' BOAR-OF HEALTH
-./0-w........ -----OF_ erAa ,09'10/.. .....
Appliration -fur Mopoiittg Works C omarnrlinn Vrrmit
Application is hereby'mado for a Permit to Construct ( j1111"or Repair ( ) an Individual Sewage Disposal
Systz:� ._ cf' �
-
®�
�1�[��� at'qn;6ress�---------•------------------ - .or �d /1L
V ........
s j � 8
------•---•------
Installer Address pp
Type of Building ' Size Lot_..L. __ ��_Sq. feet
Dwelling—No. of Bedrooms..-------------
---------------------------- Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------................... Showers ( ) — Cafeteria ( )
Q' Other fixtures ....._------------------------------------------------
W Design Flow.........lltb.....................gallons per person per day. Total daily flow--------------------------------------------gallons.
9 Septic Tank—Liquid capacity------------gallons Length................ Width-----------_--- Diameter__---_-..--.-_ Depth.--..___._._.
' Disposal Trench—No____________________ Width-------------------- Total Length--_._____-_______--- Total leaching area-.......------------sq. ft.
Seepage Pit Not' /#O� Wameter____________________ Depth below inlet____________________ Tolal ej wing area-------_ ........sq. ft.
Z Other Distribution box ( ) Dosing tank )°� `` Ar�r P'/" � ' -
'~ Percolation Test Results Performed by.__.__-..._. —:._-/',--____/__`7__"____________________________________ Date_. F
Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water_---------------------
44 Test Pit No: 2________________minutes per inch Depth of Test Pit.................... Depth to ground water-_.--.---__._--._-_----.
9 -----...-W •-- -•------------- ;� .........................................
Description of Soil Q-_�. �_ .... l ----------------------- •-------
U ..........
. � Z -------------------------------------------------
W
UNature of Repairs or Alterations—Answer when applicable-------------------------------------------------- ._--_.-----_.-_-. -- ---------------------
------------------------------------------------------ ............--------------------------------------------------------------------:-- -------- ------------------------------------------ .........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I 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.
igne .....
Date
Application Approved By..-"----�% -- - - --•r. -••-- '4/J/1 �' �...7 7--------
Date
Application Disapproved for the following reasons:...................._...........................................................................................
----------------------------•--•---•-•------•--_._....---••-•-------•--------•-•--•---=----------------------------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued...................... .................................
Date
No........&.?.-------_. ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ .....OF......3. ....................................
Appliration -for Dhipoiial Works Towilrurtiott Vanift
Application is hereby'tnade for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
77 lt:�
,. 9
o_.
cat Address ------------------------
: r.............�•�i---•-••� Owner__...-----•-•••..__...••. --•--------••-• 16 / ��AL.J ' &a s L(✓/ �--
Installer Address
Q Type of Building Size Lot...... ?-a� ..Sq. feet
V Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type of Building ____________________________ No. of persons..._____---_______--.___-.-- Showers Cafeteria
dOther fixtures ---------- _
WDesign Flow.........1.0W.�---------------------gallons per person per day. Total daily flow---------------------------------------------gallons.
94 Septic Tank—Liquid capacity------------gallons Length---------------- Width---__--_------ Diameter__---..---- _.-_ Depth----------------
W Disposal Trench—No--_-_--___._ Width-------------------- Total Length-------------------. Total leaching area--------------.-----sq. ft.
Seepage Pit Nol/Al �_Kmeter____________________ Depth below inlet....................�To a]le �litig area-------.----------sq. ft.
z Other Distribution box ( ) Dosing tank, )- // ;l J C *' '� 7
a Percolation:Test Results Performed by------------ ----_ ..-.----a----___H_____-_---____-_!_V___-__-____-_______ Date_._._ __._._.__
Test Pit No. 1................minutes per inch Depth of "lest Pit_.-----__-_______-_ Depth to ground water-------------------------
f14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.--.---__---- _--.-.
9O ---------� ,,�ff -•--•--�--•--- •---- ------•-----•-• -------'-----•-•---------------------------------
x Description of Soil... ------. .n_li-- �slf C + � '
W
a--------------------_ --------------------------------
V Nature of Repairs or Alterations—.Answer when applicable--------------------------______.-.-_-__---------------------------------.----------------------
----------------------------------------------------------------------------------------------------------------------------------------------------------------- -•--••--------•------•---------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I 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. .
• igne Q�tip' = _ ------------------------
Date
Application Approved BY----r--------r - - ..k...lfl•----- ------------ ------ ...-.. -'7---------
Date
Application Disapproved for the following reasons:...................:....:. . -
---------------------------------------------------------------------------
----------
--•-•-••----•-••---•-•=-••--•---••---•-•-•------------------------------------------------------------•-------------------------------------- ---------------------------------- .....................
Date
PermitNo.......................................................... Issued.......... -------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
e ..
• , . filer#i�ir��le •�f f��am�It�tttrr �.-'
T S IS 0 CE " IF , That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by - _
has been iiMf lied in accordance with the provisions of Art' of The State Sanitary Cog as described in the
application for Disposal Works`Construction Permit No.."................/,/-_f�_.___---___ dated--._-�'_&_77...................
T:o E ISSUANCE OF THIS CERTIFICATE SHALL. NOT ,BE CONSTRUE® AS A GUARANTEE THAT THE
4 SYSTEM WILL FUNCTION SATISFACTORY.
DATES-----•••--•-. �•-;------ .............. Inspector--
THE COMMONWEALTH OF MASSACHUSETTS'
/^7 BOARD HEALT
p �y� Z....... ..OF_.... ....... ...
` N�•------��J-...._... FEE-•-•/V••---••----•
r tt rttrtittrr>ati
PermiPermission ' y granted.'" FR- --
ssion --'•••-• ........: :.....a;...,..__ ......_._....---------
to Constr �'t or Re ir• Individ S wage os 1 ystem
at No< Gr/---- /, , ......�---- - '
treet
as shown on the application for Disposal Woi cs Construction Pe No:.. .........: .. Dated-.. ..............7.._______._..._
i
�s S� 707 Board of Health
DATE.................................................................••-•--••••-••_••
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS - •'i" "
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ol
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11145- OAAENT J.-THE oFrSETS SNoWLD
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t ' !sr° `, y , r,,' roc •• •''
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;�t,, _i•s ��r `.. \ ,(� , r,,� OEERAL NOTES
N 38z=r E �'=`�y� , J }'��` •� '►t� /� i) `tV !' , s 4 'I t �yi?�1 • ..r i
. i+.'. 1v+.�.w 11""-�•t �_ , r r��,� y✓T yap'-- '�C�.
� sfM
40-
• y i',•�L r� �a i "" x' 1)OONSiRtIED AS PROPEtiiY LIE EXlST1�G OOPDiIl01VS SURVEY.THE INEW OF THIS PLM 5 70 DESIGN A SEPTIC SYSTEM FON AT lAg1S� THIS PI/W IS NOT 1D BE
CHAIN LINK FENCE 7- t ,�.c -,t U'rr
, ,, + • •i' 2) LOCUS AREA 6 OOINWED OF
Z I x `; tirr i a► r{.� •_ r-f_ s , �- �" �1 *•s�4 ZONE AP «AQUFER PROTMI N OVFRIN DISTRICT
25.32' TP PROPOSED 15M GALLON t 7S--c. .�1� -• A. R'S WP 12D Py1RRCQ 107
SEPTC TANK - ` ,e'L �. r �,' L^. { }�.,a .� i` ti. LOT 31 AT PLMI BOOK 2B2 PAGE 58
I \ i4
F - \ j 1 / t r <sa ", •-.'a � ` ''. r :+> � _ ~ ',; ` THE PROPERTY LJ�E NHI THAN 6 AS SI M PER THE DEED REWORDED AT THE SYMIABLE COUNTY REGISTRY
OF DEEDS N DEED BOOK iLI017 PAGE 25Q
/ / \ r. • ,y, ,• ,• �' . f 3) ONNEk JOLN F, A � DOROiNY P. REM
PROPOSED ' i" T a bafr , *" i s r'^• 63 CFESW NLL AVEN(E
18�'X3y4. + y r� �, ;, v �,SPbwdr { 1�+�' , r<�]�, .i u ti!,s •S ( r BRIGHT0K 1M 02135
•� / , - �, �(� �// \ P yrt .< < ..} j v, •7._.. *�•ke; '^'+Slj y' 7J4 r rr +�
arl/jN -- � w � , _ `' �"r �, �,.•�.�''' �,�,}, �a♦ �4' [ 4) PRO�C.'T BE1rf:FMW6( •
CORNER OF D= /� n DMK)
/ /- �► / �i. ' �. ........ .. I.f• a•� ``�rr•• w•rtnl'•`1 t � �Si+4'� ,•st �.S�r •tS1'ti�,,,,, f.�1^t.� lav^c^ tea`.'^/
• ✓ _
/ // , / ? /` \ �- �� f��� ✓ • ow`� " 1 .d•M` �` ti� tip, tbsd ry4.1(f f „ r ` Q. = 4N3.13'
/ � -�- _✓ �,Ll� 15 ra >�M«fa<4. '��w'. i f ,1.L1-.. ��r"Y��•. 4 .��b�-��f _�1 •f t �
/ / -- ' - / - / �r.fro ,�^�, ,1,� � ....,Z�j '';t``y ;d;�{�i.'••' ' ::f'' I', ; 't„-ti•• ; _:� c`rr�ny„� 5) 00STNG CONDITION NFORMU N TS FROM AN ON THE GUM SURVEY,
- ,-----nit/ �1LV0 ' _...� `1�„Kdl, ` '•; .P'�".�:" ' '`Y}`'�� i �' 3 :Y. t 5 tr, + •. ON IRY 14, PERFORMED F BOXIER ABLE
Dt 2009 MO FROM pS NFORWUION OBTMED FROM 1H: i0111V OF BAi�TIIBLE pS
DEI'ARTIE'1NT 11E CIS NFORINTiON 6 APPROXWTE F ANY DOSING WHORMATION SWIM 6 DETERiNED TO BE
NACCIMATE OR N 00l =NRH THE DEslpl, THE CONTRACTOR SHALL CONTACT THE ENGNEER i�DMTEIY FOR
MAP 120 _ _
FORGET. 107 / - \ LOCUS MAP Scale: 1" = 2OW IREVEw AND PoSsIeLE REDESIGN
o 17,22E SQ. FT
6) COINAW MR M11�7E 250001 MIS D OF THE FLOOD INSURANCE RATE IMP DEFIES iM AREA AS
0.4 ACRES ZONE C, AREA OF MNALLMAL FLOOOING.
BENCHMARK: r..
CORNER OF LOWER DECK W y •SITE 6 NOT WTTFNI AN A.C.EC. (AREA OF CRITiCAt. ENVIRM MENTAL CONCERN).
� -` �F - dJ ELs48.13 \ NITROGEN LOADING LEACHNG�s FE QRON�FaSoRMAnoN •�ILO WM RM1.AREA
OF'E:SiTME TiAB�IfWATS OF
MW ( PER
40,
\ KDIW
RESIDENTIAL- 3 BEDROOMS FOR USE i TH THE W NEiIM PROTECTION ACr R UlAIM (310 CMR 101'
i I + 1�,, 110 GM BEDROOM •SITE DOES NOr CONDW A CERI FED VERIK POOL PER MESP MAP OCTOBER 1, 20M
i I i�'49e TOTAL DESIGN ROW - 330 GPD (330 MINIMUM) TERTFED VERNAL POOLS'
° ! '? Q GARBAGE GRINDER (NOT INCLUDED) - N/A
/ I / O4c. •SITE 6 NOT WM A PRIORITY WON PER NIESP MAP OCiOBER 1. 2008 1'RIRITY
Qlr �° \ HAITIXTS OF RARE SPEL'ES' FOR SPECES UNDER 1HE MASSADIUSETIS DIDANGERED
PERC RATE - <5 MiN,f INCH (CLASS 1) SPECES ACT, REGU/ATINS (321 CMIR1o).
LTAR = 0.74 GPD/S.F.
u \ \ MIN. LEACHING AREA OF SAS. REQUIRED: • SITE 6 WITHIN A ZONE (M►ELL}IfAo zaE of LaDNiIRNBLIITDN)
330 GPD/ 0.74 GPD/S.F. = 446 S.F. MiN.
/ j i � • SITE 6 IMi�/V Z01E OF CONIT118UTION 10 A SALiNMIIER ESTIAIRY
PROPOSED SYSTEM:
LFACFNNG BED CONFrA)PATiON, 4 CHVA3ERS X 4 CWAMBERS: 8) UTILITY NMR710k
N , ( BENCHMARK: -DOING SEPTIC SYSTEM 01FORM11ON 09MM FROM TITLE-
TOP RIGHT COR4R OF - I v \\ b W EFFECTIVE AREA: 1.B7(4x2B 14x6.33) - 474 SF 5 a� N� 24, 2003
BRICK LANDING EL.=46.79 ( \ &
+ \ - TOTAL EFFECTIVE LEACHING AREA - 474 SF -ALL OTHfR UIVRTIES SHIOiM ON THIS FUN HERE FIELD IACAiED BY [iufTER MBE ENGNEERNG !t SURVEYING
SYSTEM DESIGN CAPACITY s 474 SF x 0.74 GPD/SF - 350.1 GPD ON ANY 14. 2009 BY DIG-SAFE MA►OM
� SEPTIC TANK SI21<VG: 330 GPD x 200% = 660 GAL
USE 1500 GALLON TANK (MIN.) SEPiiC SYSTEM CONSTRUCTION NOTES:
' \ SOL LOOS - RM 6/22/00 1. ALL SYSTEM COMPONENTS SHALL BE INSTALLED N ACCORWO" WITH TITLE V OF THE STATE SANITARY
Hvr \ "As CODE DATED 41211M AS AMENDED THROUGH THE DA7F OF THIS PLAN, & ANY LOCAL RULES &
13ARNSTABLE Bt)H AGENT REGULATIONS APPLICABLE
• ,` � ( DAVID STANTON
1l 'f` 1• .tAP� �, �` U SOIL EVALUATOR: MZ MY CHANGE tJs1 CN NNG THISwIT� rwRTrT MUST �ET► PRIOR AP APPROVED Pto1/ T WRITING �HEENGn THE . ELEVATION INFORMATION
�� •��, �; � ,�� / , / SIEVE WIL.SON PE
/ M.
1 / 3. WHEN 6 COMPLETED, PRIOR TO BACI(FILLING, NOTIFY THE BOARD OF HEALTH AGENT' AND
•c�, i TEST PIT 1 TEST PIT 2
DESIGN EN(NEER AT LEAST 24 HOURS PRIOR TO COMPLETION FOR INSPECTION.
\ ; G.S.E. = 39.8 G.S.E. = 39.6
i f- 4. ALL SANITARY DISPOSAL SYSTEM PIPING TO BE 40 SCHED 40 PVC. UNLESS OTHERWISE' NOTED HEREIN.
Ap • 10YR 3/6
/ / \ SANDY LOAM Ap ; 10YR 3/2
5, SANDY LOAM 5S�ROU DMG THE� FIELD. � WIN�CL�,PERR310 CAIR 15.22555TTO TTHHESTOP
v> H
ELEVATION OF THE SAS. NOTIFY DESIGN ENGINEER FOR INSPECTION OF OVER M AT LEAST 24 HOURS
\ \ Z B ; 10YR 4 6 B ; 10YR 4 6 PRIOT TO COMPLETION OF REMIOVAL OF UNSUITABLE MATERIAL
\ \ o / /
16" SANDY LOAM 14" SANDY LOAM S. INSULATE ALL PIPES AGANSr FREEZING AS REQUIRED WHEN LESS THAN 3' OF COVER
/ 7. THE SEPTIC SYSTEM DESIGN DOES INCLUDE GARBAGE GROW DISPOSALS.
Z C 1 / a !� THE CONTRACTOR SHALL CONTACT DIG SAFE (AT 1-•888-DIG-SAFE] AND UTMY COMPANIES TO
10YR 5 6
w \` \\ ~ _ // ' MEDIUM FlNE SAND C MEDIUM SAND LOCATE ALL DMING UTILITIES, AT LEAST 72 HOURS BEFORE THE START OF CONSTRUCTION. THE
130" 54" PERC TEST O 5s" CONTRACTOR SHALL DETERMINE THE EXACT LOCATION. BOTH HOR20NrALLY AND VERTICALLY OF ALL
EXISTING UiM1ES BEFORE THE START OF ANY WORK. THE LOCATION OF EXISTING UNDERGROUND UITUIIES
oy v> = r Z C ; 10YR 614 ARE SHOWN N AN APPROXIMATE WAY ONLY, MAY NOT BE LIMITED TO THOSE SHOWN HEREON AND HAVE
/ \ 2 / NOT BEEN NOEPE MMY VERFED BY THE OWNER OR ITS REPRE.SWATI E THE CONTRACTOR AGREES TO
MEDIUM COURSE SAND BE FULLY RESPONS E FOR ANY AND ALL DAMAGES WHICH MIGHT BE OCGSIONIED BY THE CONTRACTOR'S
132" FAILURE TO LOCATE THE UTILITIES EXAMY. F ELEVATION INFORMATION DIFFERS FROM PLAN INFORMATION
THE CONTRACTOR SHALL NOTIFY THE ENGINEER IMMEDIATELY FOR POSSIBLE REDESIGN. AT UTNJTY
CROSSINGS, VERIFY N FIELD THE LOCATION / INVENTS OF ELECTRIC, GAS, TEIBDHOW & DATA/COMM AND
NO WATER OBSERVED NO WATER OBSERVED RELOCATE F CONFLICTING WITH PROPOSED NVERTS PER THE ENGN IM DIRECnON. THE CONTRACTOR
\\ OP PA a►} S >S Qo' \ TO 13CI" TO 132" SHA1. PRESERVE ALL UNDERGROUND UM M AS REQUIRED.
(EIEY. 28.$) 9. THE PROPOSED UTILITY SHOWN HEREON ARE SCIEMATHC. FOAL LAYOUT SHALL BE AS
FINISHED GRADE \ \ Q.3"�, 7700, (EL EV. 29.0 D BY THE APPROPRIATE U IIJTY COMPANY.
36 MAX.-9 MIN." COMPACTED FRILL, \ DEIGN SCHEDULE WATT N
" ♦ \ '' TOP OF CHAMBER pIrS` SITE LOCATION:
2 LAYER DOUBLE WASHED STONE
.. ... . .: . . . . . .
1/8" TO 1/2" OR GEOTEXTILE f CUB \ BASBM FLOOR ELEVATION 402
�: of EXISTING INVERT AT FOUNDATION N3s.0 64 Oldham Road
FABRIC PER 310 CMR 15.247 4;k we PAVI�
EFFECTIVE o 4A►T INVERT INTO PROPOSED SEPTIC TANK 37.8 OstervIlle, MA
CLEAN SAND DEPTH L 11 r . `' OVERT OUT OF PROPOSED SWTIC TANK 37•5 PREPARED FOR
PER 310 CMR ,�, ; `a �� AM R OVERT INTO PROPOSED D-BOX 37.1
5.255O,q b �. INVENz'r OUT OF PROPOSED D-BOX 36.9 CAPEWIDE ENTERPRISES
INVERT INTO LEACHING CHAMBER 36.7 P.O. BOX 763, CENNRVILLE, MA 02632
NOT TO SCALE
BOTTOM of LEACHING cH1AMBER 36.1 508.428-4028
PLASTIC LEACMIG CHAFER
LEACF�NG TRENCH CROSS-SECTION fTYPICAU I CW" THAT N APRIL 1995, I HAVE PASSED THE SOIL EVALUATOR EXAMINATION APPROVED BY THE
DEPARiMENT OF E'NnRRONMENTAL PROTECTION AND THAT THE ABOVE ANALYSIS WAS PERFORMED BY ME
ADS-BIODIFFUSER 11008D (OR EQUAL) CONs6TENT WITH REQUIRED TRW". EXPERTISE AND EXPERIENCE DESCRIBED N 310 CMR 15.017 REPAIR PLAN FOR
LAY-UP LENGTH 76" PER UNIT LATE ON-SITE SEWAGE DISPOSAL SYSTEM
TYPICAL SYSTEM PROFILE nmm amw
NOT To scwLE 36'MAIc.-9"MtN. � Tm `.//\//\j/\XM"//\ \j/\j/\ � B�R ENGINEERING & SURVEYING
/ / / / / •
NOTES: 2" LAYER DOUBLE WASHED STONE 1//8" TO t//2' . . . . TOP OF Q111EER
1. ALL MATERIALS SHALL MEET H-20 LOADING REQUIREMENTS IF PLACED OR ZoTixix� FABRIC v O O O O Registered Professional Engineers and Land Surveyors
WITHIN 10 FT OF A ROADWAY OR DRIVEWAY. _ §� . . n
CLEAN
r EFFECTIVE 78 North Street-3rd Floor,Hyannis, Massachusetts 02601
PER 10 CMR m �+
15.255 Phone - (508) 771-7502 Fax - (508) 771-7622
SET FRAME a COVER TO rIRM 6• of
TOP OF FiIV6Fi FLOOR ELEV. = 47.8SET FRAMES COVERS TO WRHN 6' OF
FINISH GRADE: RISERS 1M COVERS SHALL FINISH GRADE InSFRS � COVERS SHALL
� `1y
EXIST. GRADE = 41.3 FI wATGRADE BE WATERTIGHT �•) �N
10 0 10 20
FINISHED GRADE OVER TANK = 40.5 FIISFED GRADE OVER D. BOX = 40.0 FTINiSf1ED G
BASEMENT FLOOR t]..EV. = 402
GUM OVER LFACHM TRENCH = 40.0 SCALE IN FEET rro.3wie
SCAM(ACiF).D 1"=1 O' ' TE
6 .
ASSUMED DEIST. 4 SCH 40 PVC ,. 3' MIN. 3r (�) Cow Cow INSTALL ONE INSPECTION PORT N s'alftAL
NV OUT = 38 0 •" ` ACCORDANCE WiTH MANUFACTURERS
2.8' �'09 Tn _6" MAIN. r_ 12' r FIRST 2' (TO BE LEVEL) 2' LAYER DOUBLE WASHED STONE 1/8' RECOMME)DVITKUNS
VERIFY IN _ _
SEE GENERAL NOTE INV N= 37.E 10' MIN z NN OUf=37PVC .5_� 2• 4' SCH. 40 PVC TO 1/2 OR Gf�iEXTIJ: FABRIC PER BNODFFIlSE1t 1100BD (OR EIRIAL.)CHAMBERS D BOX
c #5. v NV IN- 37.1 :► LEACHING 4 M 11001ID OR
Cr SUMP . OUT= 36.9 4• SCH 40 PVC CaVr16E t5 � lV
GAS BAFFLE Cf. C90BER INV N= 36.7 r DATE: 06/01/09
C REINFORCED CONCRETE 14• + 6. CRUSHED *s M l�
STONE BASE • . _ BOT.
6C�RcUSHcED 36.1 DUST. IJNE IN (TYP.)
j r« •� .77..•.+'•��,i,•s < ^ ' :. 7•.:.': STONE BASE W
•».: 2.8'
DIS I FOUTION BOX i- 25.32'- vs p
UM GALLON �ARTMENT SE"M TANG ro BE INSTALLED oN A LEVEL STABLE BASE UNSUITABLE SOILS F ENCOUNTERED BEM THE 5 MIN NO. BY DATE REMARKS
2 OU LETS REQUIRED PFASTONE t]EV (TOP OF SITS). STALL 8E REMOVED 10 P VIEW DtiAwN t31f• MAIM DESIGNED W BY: DRAWING NUMBER
TO BE INSTALLED ON LEVEL. STABLE ERASE THE 'C HORIZON' AS REOUIRED - SEE CONSTRUCTION NO GROUNDWATER OBSERVED TO ELEV 2L3.6
SEPTIC TAN( TO BE INSPECTED a CLEANED ANNUALLY NOTE #5 HEREON. SOL ABSORPTION SYSTEM (SAS) NOT TO SCALE
JL
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NTS JOB #2009-019