HomeMy WebLinkAbout0075 OLDHAM ROAD - Health 75 OLDHAM RD, OSTERVILLE
A= 120-112
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No
THE COMMONWEALTH.OF MASSACHUSETTS
BOAR® OF HEALT
...OF.......
�Q- ZI ..� ..................
Allp irFa#iou for MopooFal Workii Tonstrnr#ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
S stem at
......_�G. .............. .. .--- ---------------------- e� �� : :� :--------------- ............... ,
or Lot No Locatddress .
...0... .._._..._ LEI, . - --- , - �s
- Owner ddress
---------------------------- ----------------------------------------------------------------------------------------------=---
Installer Address
Type Type of Building Size Lot__4- r_� ....Sq. feet
U Dwelling—No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building __'No. of persons._.______�,.__.__.__. Showers — Cafeteria
Q' Other fixtures ......................................................
Design Flow............................................gallons per person per day. Total daily flow-------_....................................gallons.
WSeptic Tank—Liquid capacity.______.____gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No_ ____________________ Width.................... Total Length.....................Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.....
Z Other Distribution box ( ) Dosing to
.
) . /.. ------•-
_ l j�U ..--•--•• ate.Z` ,
D
� __.. Z—,
Percolation Test Results Performed by____________ _______ ___ ___
4 Test Pit No. 1.__��. minutes per inch Depth of Test Pit.................... Depth to ground water________________________
fT4 Test Pit No. 2.. minutes per inch Depth of Test Pit_ ________________ Depth to ground water........................
O Description of Soil---- '-- -----L. '/ _.... 5�?/ -----------------= .................----------------------------------._....._.....__.
x
W ---••-•------------------•--•-----------••-•-•••-------•••----••-•--•••-•---•---•---••-•---••••----•-----•-•-------------------...-•--•----•••-•---•-•---•-•---•----•-•-•----------••-•-•---•-----•-•--
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIME 5 of the State Sanitary Code—The undersigned furth r grees not to place the ystem in
operation until a Certificate of Compliance has been is d'by the b rd of h It
Sign -•� �
- ----- <--•------------•--- i
t
_, ate
Application Approved By......... - -=•••-- •. -------- --- Da-el"J.:.
� = Date
Application Disapproved for the following reasons:.............................................................................................................
_ ................................................•----------•---•---..._......-----------...._......-•-•---•--•--••-----•------••••-•-••••-••••--•-•••---------•---••-•---••--•------•-•-•-•----•-•_•--•-
Date
Permit No.........-•--------•••---........._ .. Issued----------------••-•-••----••--••=
I� y r .............
Date
No. • ---,/D----- Fus................�✓_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD _ F HE T
-/ ....OF......
1' ppliratinn for Dispog al Workii Tonstrurti.oln 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
S stem at:
Loca ddress or Lotj No.
� . ner ddress •• /
::. ------------------•--••••................ •-----•..._...----•----.._..._._..._..........-•••-••-••......••-••-•---_._. ...._•--•-•-•--
Installer Address ���pp
Type of Building f Size Lot.f+,`�y....'°....S.l..._..Sq. feet
�., Dwelling—No. of Bedrooms.......:....................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building _ No. of ersons.__.___.. __.__..___ Showers = Cafeteria
ate' YP g -------------------------•- P ( ( )
Otherfixtures --------•-••--•-•-------------••---•------------------••••-••--••-----•--•-•-•-••••---•-••--••-•----••-------------•------•--•..___-•---•----•-•----
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid*capacity............gallons Length---------------- Width................ Diameter______________._ Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area......_.............sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area.................. . ft.
Z Other Distribution box ( ) Dosing to ( POP
Percolation Test Results - Performed by.._._.___.I.i .�_ _________ _________________ �G� � ...„�
�.7 '�. --------- Date----•- _- a -w^-
,� Test Pit No. I_�_�minutes per inch Depth of Test Pit____________________ Depth to ground water........................
Gz, Test Pit No. 2_________ mmutes per inch Depth of Test Pit.................... Depth to ground water........................
a __�_
ODescription of Soil.._"_ ... - - -.................---00./ •-......................................................................................x
U •-----------------------------------------------•--------._...--------•----.....--------••----•......---•--••---------
W
UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
t
..------•-----------•--•----•---------------•------•---•....._-•-_.._..-••-••-----•-•---............--•-••••••-••••------••-•-----•-----•••---•---•-----•--••-••--•-••--•••-•--•------•-••...._.....----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T j,i.
p of the State Sanitary Code— The undersigned f rth r grees not to place the system in
operation until a Certificate of Compliance has been is u d by the`haard of h 1 I
-Sin ---�-- -- f..
g = ..
C Date
Application Approved By.._..---�- „- - - •---•--- = --- --- ---1!�L.!'�� - .A.........
" �J
V Date
Application Disapproved for the following reasons_............................. .................................................. =.........
..........................................•--•--•-•-----------....--••------------------....-•-------------••-••-•--•--•-•••---•-••-------••-----•------•-----••••---•-----•---••-----•-------•••-••-•-
Date
PermitNo=----------------•--------------•--------•----•-•-------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Ja
F HEALTH
J` /.
......................OF....... .........................
TUrdif irFatr of TontpliFatta
IS i 0 T F T at the Individual Sewage Disposal System constructed or Repaired
,(C g P �' ( )
by.. _.. � ...�r� ..... :.
.........- s
-----------
-�^ Install �►/
at 1 ..--✓- -•--... . ._ --------..__' �j� `!
has been installed in accordance with the provisions of T� 5 of The State Sanitary C de as.described in the
application for Disposal Works Construction Permit No•_. ___._,j`'� �_______________ dated_-... '`1�_.:._�� _'............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �
/DATE............ ,_ / •-
p .8THE COMMONWEALTH OF MASSACHUSETTS
BOAR F HEALTH '
Wt
A f "���. d../ ,,�.................OF. '' ~ r-�-!�'..____.__....-..-_....._..._........��IJ J
No............. FEE... .............
i �rrr 1 nrk n
2otrurtion
erms h II amit
PiiY � � la -----------------••-------------------.....---•--......___.r._...............-•-----
to Constr�ttCct/{ ) '"a Ivid Se ra Di posal
at No..... -----1✓..........? ,f -- '" - %�---------------------•--
t .,.:...
Street
as shown on the application for Disposal Works Construction Per< No. .__.r�.____ _ Dated.......l-.� ls_-_. .'....:
•••---• Board of Health
DATE---------------------------••---•-------._.......--••-•--•-•---•_---•-
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - -
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
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LEGEND.
CERTIFLE D PLOT
E�fhST(ND, ,SP®T ELEVATION Ox0 � ,PL'A:N
E)(I.-STING CONTOUR' O.
, 11lSI�ED SPOT ELEVATION ;
FINISHED 'CONTOUR 0
APPROVED s WARD OF HEALTH y
•
71
OATS AGENT s
$,CALEll >,; .,OATEN a
_ DREDGE 'ENGINEER/NG CO. IN s - l�r�i
CLIENT I CERTIFY r THAT THE PROPS °
EGISTE rREGISTERED J06 N0.` BUILDING SHOWN ON THIS . PL'A�15.
CIVIL LAND
E INEER SURVEYOR
DR.BY,f� • `ip r2?, CONFORMS TO THE ZONING LAB r `
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Nb .M/N..P/TCN /c1 D o GAL.. , �'::o e • .` . • -' b �4e bq/ASHlSD 5"MC
Piro r-r. SEPTIC TANK D/ST. ' s s �. o . • • ® ,o
v o � � o •- • oo ., . . M
.:BOX
€ '� i.. , - . . - - : s - ACT/✓�, e. '�
t:o s;DEP� • B e. • 0 1464SNEP STOVE
- �: � PRECAST SEe�.f1AGE
/Ni�L'RT EL EVilTOGuV� � �-[ •�s�1 � ' ® a TM
' l*Yrmr AT OL//LD/NG . 7'�'FT..
6 s• _ FT. w/A/►�/. C(SEE 7A&/A.A,r
` �oiv� "
//YL7` .A�'PTIIC TANK _� / � FT...
OU7L VT SEP7YC TANK PT.
/MLE7 0/STR/0!/T/ON ®OX G FT GROUND / ITE/� TA�ILE
� .SEG'T/CN 4�
06/TLETD/$TIq/O(/TYON DQX FT::
' /NL.ET LEACN/A/G. o.4T `,!5,4 S�y1/AGE O/�i®O�SA L 5�•3��*M 'T�401lLAT/ON
LEAC'N//V6 PI T
A
sc.�LE : 4 p -v" DMEN.�/ON
DES/S/V CR/TER/�l D1AlAs 5l4JV B-/S_F'T.
Nl/MeER OF BED+ROO/►15 � � D/MEd�S/ON C�FT. /ems r.� .:
WRQAGE D/SPO.SAL UNIT SOIL LOG
TOTAL ArST//�TBD FL:O,W 3 3 tr G.4L./qA� DSO/L TEST Ak/: $O/L' MWTldF2 ®V� TEJT
NUMBEE OW 40ACNINT P/7a . -7 ,DATE OF 'SOl L TEST
S/Ols..LEACH/NG PEI t AM Pr
PT. I
#VESUa-TS P//TIVESSED BY
OOT7OM:LA4CN//V6 PER /P/T E IaT: SRC®La�T'/0/V RAET� /• SS M! IIVCN
TOTAL'.LArAG'N/NG AR&A S4g FT. 1 *1�C®B/��'ABId RA7,F ' MIN.�ING�
RESJFRIiEL G'i�4CNlN6AREA -2. c, iJ. c
FT
�T gVh'dQ\V„ 3 / Z:. - Fr. r+ Z� ,S, !, "�; r,`,,,i •..
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r STEP�a�`�; 712 /"Al"
ST
` { FSS'pNA'6 °&�. G'®�'s41�' t�f® 111r�AA/fi91�s
M Cad!'®ddAlDATI� Ate. m___. JtJ� !� 3 SSNERGIR'.7
TOWN OF BARNSTABLE
:LOCATION :7,$ OL DdAfl (9a( SEWAGE# c7O OS3
VILLAGE 054eru;11 c ASSESSOR'S MAP&PARCEL Jim J/2
INSTALLER'S NAME&PHONE NO. Q B EXcA✓ 717. OGS 3
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) f/.70 ARC �'�G (size)
NO.OF BEDROOMS 3
OWNER Mcrskq
PERMIT DATE:�!�•G- J01 COMPLIANCE DATE: 3•$ • J�,
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
A � ? REAR V
gg• IT A
Ay 0
FI
qs• y3.S 3 s
gs- Y7'
A 41.1`
3G , y2
A -
TOWN OF BARNSTABLE
LOCATION 0�"W SEWAGE #
E D��E JC U/IIg ASSESSOR'S MAP&LOT I. yrf
INSTALLER'S NAME&PHONE NO. CI
SEPTIC TANK CAPACITY
LEACHING FACILrTY: (type);��' ts�1 �s�'��� (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: q_5_ OMPLIANCE DATE:e 7
Separation Distance Between the:
Maximum Adjusted:Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility)
Feet
Edge-of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
y Ng fv
add
L PT
5/0
L-0CAT SEWAGE PERMIT NO.
VilLAGE
INSTA LLER'S NAME i ADDRESS
1
d U I L D E R OR OWNER
DATE PERMIT ISSUED q
DAT E COMPLIANCE ISSUED f
O
.1
NO. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
<0kN6 OF +
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair (' ) Upg> de ( ) Abandon ( ) - ❑Complete System ❑Individual Components
`15 0I dh C]
�Gt'[ion 1 ( 1? 76
o Cd h �Wame l
�1� LP,1
Map/Parcel# r 1 �11,e L� .
Lot# Telephone
I - In Caller's N V � ��� � signer's
5 0�v 44—I`! — s ��ll' 2- Lls T dress I
Telephone# Telephone#
Type of Building: eslAen C9 Lot Size Sq.feet
Dwelling—No.of Bedrooms �� Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(mi .required)330 gpd Calculated design flowY>" gpd Design flow provided �-Fgpd
Plan: Date 5 Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date ,-� 11. 1 t 2-,
Inspections —C' fa—
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
.-s ti - , �}..,,`,, �-,. 5r„ ..�r� ',�.,"a,t"F.,s�-•rr."rs�'^��ar`"M�'�"+-'�L" -r. -yy-,�. �'- n,..4 .. .,�- 'r`k,... ._.
=No 'f THE COMMONWEALTH OF MASSACHLIVETTS FEE
OARD OF HEALTH
<0NOT
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ) rAde ( ) Abandon ( ) - ❑Complete System ❑Individual Components
'15 oldhomP-p►
Location '_ �7 Owne ame
�GD I ��tr/P_1 I IZ 16 o 1E+IhCtfTl �S 1��vi �
Map/Parcel# _ 1 609 0 + L�_2_�dd et
Lot# ,_' Telephone,#
>CC�IU _ Dr. 1� �C nG
In taller's Nam esigner's N m�
I bC(( �! o(esi�(a 9 � Qic��- �1 1, ;�nyt✓ -
ATidr s _ Address t +
50�- �I �`7- Cry 50K 36-2 - HSW(
Telephone# Telephone#
Type of Building: Lot;Size, 1 Sq.feet
Dwelling—No.of Bedrooms b F Garbage Grinder ( )
Other—Type of Building 9 No.of persons 1 Showers ( ), Cafeteria ( )
Other fixtures 1
22
Design Flow(m required)33 U gpd Calculated design flow73 gpd Design flow provided 3 gpd
Plan: Date �3 ,51 0— Number of sheets Revision Date
Title
Description of Soil(s) fr
'f 'Soil Evaluator Form No. Name of Soil Evaluator " Date,„of,Evaluatiop '
DESCRIPTION OF REPAIRS OR ALTERATIONS ,µ
L
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
i I
Signed lJ�-'t_tJ Date 316 ( 2_,.
3-G- f J,
Inspections
3
FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 +c
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
M 7 4�--C(�,
DATA
0"
No.ao 1;` 3 THE COMMONWEALTH OF MASSACHUSETTS FEE T�
&ynsfC h(-C- BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System s
The undersigned
C Ydersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired(y<Upgraded( ),Abandoned( )
by: I- i (3 .(n l/(^li �w) o
at 15 Oldham MCC 1 [ JS�U V( ' 1
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
1�
plans relating to application No.a012-655 dated 3" 6` t r Approved Design Flow 3 (gpd)
Installer
Designer:
�o w r�e. t nq • Ins p ctor 1 _sue Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. aO0Z ^ (563 THE COMMONWEALTH OF MASSACHUSETTS FEE I
BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ( "�) Upgrade ( ) Abandon ( ) an individual sewage,
disposal system at 943 n LD H A M R-O&D as described
in the application for Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit.All local condit'ons must be me
C� t.
Date _ ! Board of Health t"l ' +_
FORM 2 - DSCP DEP APPROVED FORM 5/96
i
FORM 1255 (REV 5/96) H&W HOBBS&WARREN PUBLISHERS PUBLISHERS- BOSTON
r
Ray
�:-Dl-eudator v Sep�ices
Z3
i' T harms TT. Ge¶Ten D'Iy cto
3.'•'NSTABIE7 s -
�SS. 'Hit b, fC 7ien1Lill Divisfrij n.
E639•
T homas IYlr1r;ean, Director
200 Main Street,l ly amnis,PAA 02601
M
Office: 505-962-4644 Fax: 505-790-6304
TnstaHer & Designer Certifinatnon Form
Date- 3-9 Lz Sewage Permie-' ,�01� •�4!�3 ssessor'�Map\Parcei
Desigmero
Address* �13q rnA.3 address- /&j TcaScrN Lrj
On - (�- /;1 B ExeAV was issued a permit to install a
(date) (installer)
septic system at: nL! HArn based on a design drawn by
(address)
DWcN Cane- EIJh dated /2 '
(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 the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local regulations. Plan revision or
certified as-built by designer to follow.
a• N OFOfftSs�
�QO� �ANIELA. yes
(Installers Si r )
CIVIL Cn
No,46502
� e �
esiper'S Slgnature) (Affh D� I� amp I eTe) t�
PLEASE RETURN TO BARNSTABLE TLWLIC fNALTH DiVIvION. CE TITICATE OF
CoriV"IANCE '-eWTALL NO BE SSUPED uTNTIL BOTH •TLAUS FORM ��1- AS-BUILT CARD ARE,
]RJECE l+B BY THE BARNSTABLE PUBLIC HEH ALgHA DMSION. THANK YOU
Q:Health/Septic/Designer Certification Fonm 3-26-04.doc
x 6.03 Q
3 PAVED DRIVE 45.89
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EXIST. DWELL 46.06
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Q� DECK. EXIST. S 47.84
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46.45 47
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12-043'
AS BUILT SEPTIC SYSTEM PLAN'
PREPARED FOR:
LOCATION : 75 OLDHAM ROAD
OSTERVILLE B&B EXCA VA TION/
SCALE 1" = 20' DATE MARCH 8, 2012 MERSKY '
r �yta1 OF
o�off. 508-362-4541 DANIELA,��fax 508-362-9880 OjALA,µ v CIVIL ,
down cape en gin eerin g, inc. No.46502
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CIVIL ENGINEERS P �FG/ 7E��
LAND SURVEYORS \ 10 uti� �r
939 main st. yarmouth, ma 02675
DATE
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Town of Bar ustab le p# /3 ,5 l 5
�;IE ro,
1DepartmQ11t ot'1Regulatory Services. d ��
y Public Health DiviSiolll �, Date
200 Main Street, Hyunuis MA 02601 r 't
UfiAA't� A
ly
Date Scheduled_ L
`oil Suitability Assessmentfor ,Sawa -e Disposals
Pcrfonncd By: ► 00,
�P°`"" Witnessed By.: rJ�
l[.,0 CATION. GE�'�_�
Location Address 7 f— O ld/ _ w\ J��,,, o Owner's Name �rf A�
�`t/�`�( Address
Assessor's Map/Parcel: ��,U/�� �C Cngiucer's Naiuc bt�✓�
ne 1
NEW CONSTRUC'1'101'd RBPr\1R Tele phb t
Laud Use• 7 . c Slopes(%) t Surface Stones
Distance's From: Open Water Body. Ft 'Possible Wel.Area Fl Drinking Water Well Fl
Drainage Way It Properly Line Ft Oilier ft
SKETCH: (Street name,dimensions of lot,exact locations of lest boles Sc.perc tes(s,locale wetlands'in proninuly to boles)
Purent material(geolagic)_{rJ�J �`�/+ t/� Depth to Qecb'oelt,
Depth to Groundwater. Standing Water in flole: Weepilig I'ronl Pit Pflce
Estimated Seasonal High Groundwater
DE T ERIMNA7['ION FOR SEASONAL HIGH WATER TABLE
L E
Depth Observed standing in obs.Bole: irt, Depllll IkIUll1531 _~�+ _lu, _ ~�- �
Depth to weeping From side of obs.hole: Ill, ClruullrJwnter.Adf uslhtent„a__ „ Pa.
hldcx Well M Reading Date: Index Well level ____„ Add,fklCtbl' At{i,C)fl?Ult(lWtier LxVel a
Observation _ IVERlCOLATI..ON TESrIr �Dlllk 3A+—'AYu'IO _
Holc It _ Time tit h"
Depth of Perc Tln•1p at 6" _
Slart Pre-soak Time @ lot �G'` _ Time(9"-0")
End Prc-soak w�U TTS
Rate Minjinch ZY Ob wl,
Silc Suilablllly Assessment: Sile Passed Sih-Failed: Additional Tesling Needed(Y/N)
Original: Public Health Division Observation Hole Data`1'o Be Coinplelerl on Back-----------
***If percolation test is to be conducted wiLibin 100' of vvefland, you must firsit Uotiity tune.
Barnstable Conseil-vl>tion Division at least one (1) vvec➢c prior to begivauiuug.
Q:\SBPTIC\PLRCFORM.DOC
t __ I
Depth from Soil Horizon
Surface(in.) Soil ]Dole #
Texture :Sdil Color •-
Soil
(USDA).. (Munsell) MottlingOther
(Structure,Stoncs;Boulders,
� Con istc c ra el
D)R EP o-RRE -R VAT
D .�Depth from So' ®N HOLE'LOG
l Horizon Soil Texture Hale #
Surface(in.) Soil F. (USDA)
Color Soil
USDA) (Munsell) Moltlin Other
t (Structure,Stones, Boulders,
Co SiS enc % C avel
—.lam41
.
/W /
' Depth From DREPOBSERVATIONITOLE LOG
Soil Horizon Soll .][�®➢�# -
5irrrace(in). jl Tcxhtre Soil Color.
USDA 5oi 1
(USDA) (Munsell) her-
Mottling . (8tructu�tSlones,boulders.
Consistency.9a Onvel]
-
Depth fiam Soil,Horizon �®�` Hole #
Surface(in) Soil Texture Soil Color
(USDA) .. Sell
(Munsell) Moltling (Structure,Stones; Boulders,
Consjstengy_
--
Flood Insurance Rate I apr y
Above 500 year flood boundary No Ycs
Within 500 year boundary No 1
Yes. _
�?Jithir, IOOYear noodboundary No YES
IDle t0� o�]`1ru�ln>rolB.Y_ cc—Il arir>ing lea lrvlrNgaterfal
DOes at least four feet of naturally occurring pervious msterlal exist in all areas observed thl'pughout the
area proposed for the soil absorption system?
Rt'not, what is the depth of naturally occurring pervious tnatol'ial?
Ceatil$--�c�taoru n
R certify that on (date)'I have passed the soil evaluator examination approved b the
Department of Environmental,.Protection and that the above analysis was perfnrmed by me consistent dvith
Ilia required training, expertise and experience described in V10 CMR 15.017,
Signature
Q:1SSPTI'CTBRCr0lZM.D0C
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
75 Oldham Rd.
' Property Address
MERSKY, DANIEL B & PATRICIA T
Owner Owner's Name
information is required for every. Osterville Ma 02655 1/31/2012
page. Cityrrown 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 filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
C y e Enterprises
Company Name
153 Commercial St.
Company Address
Mashpee Ma. 02649
Citylrown State Zip Code
508477-8877 SI 4522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection .
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of
Title 5(310 CMR 15.000).The system: f
❑ Passes ❑ Conditionally Passes Fails
6 17,1
❑ Needs Further Evaluation by the Local Approving Authority
f �
1/31/2012
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of.Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater;the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This,report only describes conditions at the time of:inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
bi - �.�V
t5ins•11/10 Title 5 Official Inspection Form:Subsurface age Disposal System-Page 1 of 17
.f
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
, 75 Oldham Rd.
Property Address
MERSKY, DANIEL B & PATRICIA T
Owner Owner's Name
information is required for Osterville Ma 02655 1/31/2012
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Oldham Rd.
Property Address
MERSKY, DANIEL B & PATRICIA T
Owner Owner's Name
information is required for Osterville Ma 02655 1/31/2012
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 75 Oldham Rd.
Property Address
MERSKY, DANIEL B & PATRICIA T
Owner Owner's Name
information is required for Osterville Ma 02655 1/31/2012
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well.water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 75 Oldham Rd.
Property Address
MERSKY, DANIEL B & PATRICIA T
Owner Owner's Name
information is required for Osterville Ma 02655 1/31/2012
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
_criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
m Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Oldham Rd.
Property Address
MERSKY, DANIEL B & PATRICIA T
Owner Owner's Name
information is required for Osterville Ma 02655 1/31/2012
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Oldham Rd.
Property Address
MERSKY, DANIEL B & PATRICIA T
Owner Owner's Name
information is required for Osterville Ma 02655 1/31/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
2010 = 142,000 total = 389 gpd 2011 = 139,000 total = 381 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4M , 75 Oldham Rd.
Property Address
MERSKY,.DANIEL B & PATRICIA T
Owner Owner's Name
information is required for Osterville Ma 02655 1/31/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Oldham Rd.
Property Address
MERSKY, DANIEL,B & PATRICIA T
Owner Owner's Name
information is required for Osterville Ma 02655 1/31/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Tank, d-box and leach pit are assumed to be original, 1980. A leaching chamber was added to the
system in 1995 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leakage, vented through roof
Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 gallons
Sludge depth:
5"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 75 Oldham Rd.
Property Address
MERSKY, DANIEL B & PATRICIA T
Owner Owner's Name
information is required for Osterville Ma 02655 1/31/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 3.5'
Scum thickness
2°
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? opened covers and took
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank does not need to be cleaned now but should be done soon and again every 2 years as
maintenance. Water level was ok, tank was not leaking and was structurally sound. Outlet baffle was
intact and in good condition..
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 75 Oldham Rd.
Property Address
MERSKY, DANIEL B & PATRICIA T
Owner Owner's Name
information is required for Osterville Ma 02655 1/31/2012
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75 Oldham Rd.
Property Address
MERSKY, DANIEL B & PATRICIA T
Owner Owner's Name
information is required for Osteryille Ma 02655 1/31/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Olt
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 was video inspected from outlet of septic tank. box had large amounts of scum buildup but
appeared to be structurally sound.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 75 Oldham Rd.
Property Address
MERSKY, DANIEL B &_PATRICIA T
Owner Owner's Name
information is required for Osterville Ma 02655 1/31/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1 6x6
® leaching chambers number:
1 500 gallon
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The leaching chamber that was installed in 1995 was found to be hydraulically overloaded. A probe
inserted into the stone in numerous locations came out dripping wet and smelled of sewerage.
The leach pit was located and opened, the water level at the time of inspection was approx 1' below
the bottom of the inlet pipe, using a mirror and flashlight a very noticable scum/stain line was
observed to be only a few inches below the inlet indicating that the water level has been much higher.
This pit is considered failed due to insufficient available leaching.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Oldham Rd.
Property Address
MERSKY,_DANIEL B & PATRICIA T
Owner Owner's Name
information is required for Osterville Ma 02655 1/31/2012
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System-Form-Not for Voluntary Assessments
'< 75 Oldham Rd.
Property Address
MERSKY, DANIEL B.& PATRICIAT
Owner Owner's Name
information is required for every Osterville Ma 02655 1/31/2012
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks_ Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
c
o �
A-Z 3.5
D 8-2 33
A'3 `-13
3e
�-I - -[qD-
30 Z6 �
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage'Disposal System-Page 15 of 17
Commonwealth of Massachusetts
H Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Oldham Rd.
Property Address
MERSKY, DANIEL B & PATRICIA T
Owner Owner's Name
information is required for Osterville Ma 02655 1/31/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
El Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
System fails inspection, groundwater elevation was not established.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 75 Oldham Rd.
Property Address
MERSKY, DANIEL B & PATRICIA T
Owner Owner's Name
information is required for Osterville Ma 02655 1/31/2012
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
} ASSESSORS MAP NO, 0R Q
1�
No. PA EL 11A
P/1�i1/Q_-_ Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
2pprication for &sgpoga[ *pgtem CCon5truction 3permit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location ss or Lot No. Owner's Name,Address and Tel.No.
Installer's Name,Address,and Tel.reo. Designer's Name,Address and Tel.No.
Kpeuilding:
Dwelling No.of Bedrooms 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
Description of Soil
Nature of R 'rs or Alterations(Ans er when applicable /� .� 6 f10
o d ,�� 14
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 iss d by this Board of Health.
Signed Date 6 o?) s
Application Approved by U
Application Disapproved for the following reasons
Permit No. 16 & Date Issued `
———————————————————————————————————————
c :. ,.'.,. jtf. . ..rr'`. ".^ ..-.. . .. .+•I � .. .:: ,.,r yh r... , r— `y -i_
No. (ff/ ^^ Fee
,.. . .. THE COMMONWEALTH OF MASSACHUSETTS 'µ
PUBLIC HEALTH DIVISION - TOWN OF--BARNSTABLE, MASSACHUSETTS
2pprication,for Mioogal 6pgtent Conmiuction'Vermit
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location A toss or Lot No. Owner's Name,Address and Tel.No. -
Installer's Name,Address,and Tel. o. Designer's Name,Address and Tel.No.
pe of Building:
Dwelling No.of Bedrooms�� Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
i
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title a
Description of Soil /0',Q
{
i
Nature of gepp'rs or Alterations(Answer when applicable
Date last inspected: ~'
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed Date C91a) S
Application Approved by
Application Disapproved for the following reasons
Permit No. Cf <t�' Date Issued.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance -
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( on
by � G1 i e for
as has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No �S dated F^Zle'"5E�.
Use of this tem is conditioned on co iance with the provisions set forth below:
No. (? Fee —'
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
ligogal *pztem Congtruction Vermit
Permission is hereby granted to i
to construct( )repair(�)an 0-site Sewage System located at b
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply.with Title 5 and the following local provisions or special conditions.
All construction must be.completed within two years of the date below.
Date: Approved by �71----s
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LEGEND
EXISTING SPOT ELEVATION OxO CERTIFIED PLOT PLAN
EXISTING CONTOUR ——— 0 —
gAiric
FINISHED SPOT ELEVATION f
FINISHED CONTOUR 0 - 1
APPROVEDo BOARD OF HEALTH IN
�+
DATE AGENT SCALES / ''
ka
9i rr: • ,
CLIENT I CERTIFY THAT THE PROP EGISTERE REGISTERED '
CIVIL LAND JOB N0.` �_ BUILDING SHOWN ON THIS p(. j
E NEE SURVEYOR DR.BY:/1 = CONFORMS TO THE ZONING LAn
_. . _• „ OF BARNST)kB�g#I MAS4.
ram,• - .. ;.,1,-� '.i.".'.::: � ��.:' ... +.-+;7.� ,C% .-
• •• ilCflNvQ •• - IW /'70R2 9"NgN I? SI:AAIV
_ c• . . . . _ - .. • ;�• ...- - : �. ��.•jy'Q/ .TER CON«I�T�' �DYt/r
m Am MIr/V .. .` �iV!RLL.�� �I4�T_TO 4*JTA OE.6AJV. m-,4 1
„ : �•�t` J'IdAVY C^ST/R'ON Go✓4 SII+ALL BE vs,&-o
MIII&/VTC/11 I)W IAe OR/VEjVAY
wliN. CbNC.�2FTE
A of GOVER CLEAN .SAV P
2"LAYER
MIN.P?G/�l U G�IL. • Selo +• • • • • m • • s • WASNPO 5MNC
i4"P�a I7 .SEPTIC TANK Eox ' ' :i a • • • + • • •'• •�
Or
V.
�;.• i • • 1 • • • • • + + o p • PRECAST SEf�GE
s + + • •: • • • • + • • P/7 OR LVV/V.
lNI2RT ELE✓�1T/OW! �L �-y,y - or
/NYEJZT AT OJ//LD/NG 9 % FT,
/NLE7 S�T/c Ti4/VK 2 C(SEE�dut.AT�ow�
OV74E7 SEPTIC TANK 9 3 FT. -
INLET DJSMUSA ION SOX b FT. SECTION OF G/PpVND IYATFR TAaLE
Ot/7ZETDV 57R/e(?ION aGX 2 FT
/MLET L--ACN/NG /�/T S S.4 FT. s�wAGE O/SI�+O�SA L SYSTEM 7A4941LAT/D/V
LEACH//VG =/7'
., _ /_ O.. D/MENJ/ON A RT
DES/6N CR/TE/'C//� JCALE : /•s D/AlEIVS10 N
NL/MSER OF dtEDNr�O/ys DIMENSION C. FT.
t &4R45ACEO/SPoAL r UoVl SOIL LOG
.S
TOTAL �T//►NTED FLow "s ? G,4L•�gg7 SOIL TEST,*/ SOIL 7EST*2 SO AL TE1T
AfIJMBEROF LEACM/NS P/T3 f'ELC'V. "% '' ELEY, DATE OF SOIL TEST S
S/DTr LtACHJNG PER P/TT_S� fT. _ _ RL�S[lLTS iV/TNCSSED dYr
/ �- C •S AL�It COLAT/ON I�ATIf�/ _L �`-' Ml I1�I/NC t
OOTTOMLi4CN/N6 PRIt P/T SQ. FT. 1 ��, AI70'rA4 LEACN/NG AREA 2 6 Sa FT. PExCOLAT/aN RATE lfE2 "" MI/V.�/NC.
A RBSiR1�EL6.4C/VlN6 AREA � � $0. FT.
na/RCBEPT\�',. /r C
v 'A BUNIKIS
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90 �G�STEP�;,� ;t 7/2 J"A/N sr..
° �Fss,0NA L6,/ No*#T*UovZp WAT`P JWCOl1NTSxE� HYANPJI9 MAaa.
". GRO UAeD W-47WiP AT ,�L.C✓. J
oB .� _
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L O C T ION �� Dl�gn Wd ' SEWAGE PERMIT NO.
VILLAGE
IMSTA LLER'S NAME A ADDRESS
il
• U I L D E R OR OWNER
DATE PERMIT ISSUED q Z
DATE COMPLIANCE ISSUED
' - 1
.T� •
't
ALL TE
S SHALL
SYSTEM PROFILE MARKED WITF{ MAGNETIC TTAPE OR BE NOTES
(NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS APPROX. NGVD to 28
PROVIDE MIN. 20" DIAM. WATERTIGHT Rou
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE
2. MUNICIPAL WATER IS EXISTING So
PROVIDE INSPECTION PORTS TO
\ TOP FOUND. EL. 46.5 WITHIN 3" of FINISH GRADE oo rh 01
MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED VER SYSTEM 46.0
3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. ° y
4. DESIGN LOADING FOR ALL PROPOSED PRECAST a
PRECAST H-to UNITS TO BE AASHO H-10
RISERS (TYP.)
, . 2 0 44.7' 4"0SCH40 PVC � aro
+; PIPES LEVEL 1 ST 2' - 60, 5. PIPE JOINTS TO BE MADE WATERTIGHT. Ke volley 0 0�
10" EXISTING 14" ' 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE Stno Lo
TEE SEPTIC TANK** TEE : WITH 310 CMR 15.000 (TITLE 5.) 6uh
*43.3' o o ;`, 42 0� i 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND Farm volley s er Ro
GAS BAFFLE °O°oo'og°o°o4 NOT TO BE USED FOR LOT LINE STAKING OR ANY
OTHER PURPOSE. %e
43.13' 42.96' 0.59 41.4'
a
8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
6" MIN SUMP
12" MIN. INT. DIM. EACH UNIT: 5' LONG x 2.88' WIDE x 1.08' HIGH 9. COMPONENTS NOT TO BE BACKFILLED OR
USE 19 ARC 36 STD. UNITS (H-20 RATED) CONCEALED WITHOUT INSPECTION BY BOARD OF
6" CRUSHED STONE OR MECHANICAL (NO STONE PROPOSED) HEALTH AND PERMISSION OBTAINED FROM BOARD Q° C
COMPACTION. (15.221 [2]) 5.1' OF HEALTH.
( 1 % SLOPE) (±Lq R SLOPE) 10. CONTRACTOR SHALL BE RESPONSIBLE FOR 12at
CALLING DIGSAFE (1•-888-344-7233) AND
LEACHING VERIFYING THE LOCATION OF ALL UNDERGROUND &
FOUNDATION EXIST. SEPTIC TANK 17' D BOX 4# FACILITY BOTTOM TH 1 & 2 EL. 36.3 OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF WORK. LOCUS MAP
*THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT
UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE 11. ANY UNSUITABLE MATERIAL ENCOUNTERED NOT TO SCALE
PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM NTH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE SHALL BE REMOVED 5' BENEATH AND AROUND THE
CONDITIONS IF NOT SUITABLE PROPOSED LEACHING FACILITY.
ASSESSORS MAP 120 PARCEL 112
12. EXISTING LEACHING FACILITY SHALL BE PUMPED
AND REMOVED OR PUMPED AND FILLED WITH CLEAN
SAND.
VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE /x 44.63
IMMEDIATELY GRANTED BY THE BOARD OF HEALTH AGENT OR
BY HEALTH INSPECTOR �
PAPERWORK AND HEARING REDUCTION PROPOSALS APPROVED p►O 5.16 �504`85 SYSTEM DESIGN:
BY THE BOARD OF HEALTH REVISED DURING A PUBLIC �►O i�5.16 GARBAGE DISPOSER IS NOT ALLOWED 5 s5 EXISTING 3 BEDROOM DWELLING
HEARING HELD ON AUG. 4, 2009 � 45. x �. $.84
3) FAILED SYSTEMS ONLY : SOIL ABSORPTION SYSTEM s 39
INSTALLATIONS PROPOSED MORE THAN THREE FEET BELOW �O � 45.67 2 w DESIGN FLOW: 3 BEDROOMS CaD 110 GPD = 330 GPD
GRADE WITH PROPER VENTING (PIPED TO THE ATMOSPHERE) O II 5 USE A 330 GPD DESIGN FLOW
AND WITH H-20 LOADING, BUT IN NO CASE SHALL THE SAS ��� 4 .90 �:Q
BE LOCATED MORE THAN SIX FEET BELOW GRADE. 00
Oh I 46. 7 SEPTIC TANK: 330 GPD (2) = 660
,x44.92 � I 3 RE-USE EXISTING SEPTIC TANK**
46.28 w I
LEACHING:
x'44.25 c `
I? 4.80 SF/LF x 5' LENGTH = 24.0 SF PER ARC 35
61 6.03 3�`ri CHAMBER IN FIELD CONFIGURATION
\ w 6.03 I3 PAVED DRIVE 45.89 330 GPD/0.74 GPD/SF = 446 SF LEACHING
TEST HOLE LOGS ' c 3 5 9 � REQ'D
crv\ �C 47.6o w
crV�CTv x 470 0 I 3 446 04 ��'- 446 SF/24 SF/UNIT = 18.6 UNITS
ENGINEER: ARNE H. OJALA, PE, SE �cry � W I
�CTv *46 6.39 THEREFORE, USE GRAVELLESS SYSTEM OF 19
WITNESS: D. DESMARAIS, RS ��v_�cry ARC 36 STD. CHAMBERS IN FIELD CONFIGURATION
DATE: MARCH 5, 2012 \0 46. 446.2 SHOWN
.2
PERC. RATE _ < 2 MIN/INCH LOT 36A SHED 19 UNITS x 24 SF/UNIT = 456 SF
15,000t S.F. 46�20 MARK _ 456 SF 0.74 GPD SF = 337 GPD OK
CLASS I SOILS P# 1356546.19 BENCEXIST. DWELL. 46.06 CONCH BULKHEAD EOLIRNER�O 3 ( ) / ( )
.10 TF - 46.5t
I
ELEV. ELEV.
' 46.20 °
O„ 46.3' 0" 46.3' I SHED M A
946.27 46.11 APPROVED DATE BOARD OF HEALTH
FILL 8„ FILL
5.87 1
$ I'll "i ' TITLE 5 SITE PLAN
/ / '�9 4 99 TH 2
A B A B s DECK EXI T. ST** 19 �p� 47.84 OF
�
LS LS � J X 46.3 ��.
10" 10YR 2/1 10" 10YR 2/1 HOT
x 45.89�j, 4 75 OLDHAM ROAD
E E TUB PROP. VENT WITH CHARCOAL FILTER OSTERVILLE
45.7 4 AND BUGSCREEN CONTRACTOR WITH HOMEOWNERFINAL MENT BY
MS MS
12" 10YR 6/1 13" 10YR 6/1 �� CONSULTATION)
!�, PREPARED FOR
B B 45.77 46 4 . +3 �ZH OF Mq
Ls Ls SS B&B EXCAVATION/
sr. OO \,•(H OF Mj ���P any
,� �O ���5 - --� sy o DANIEL (,, MERSKY
48" 10YR 5 6 42.3' 48" DANIELA. A. ``_
/ 10YR 5/6 42.3 <" o of OJALA N
46.45 .47
CI 'IL No.4 980 MARCH 5, 2012
No. 6502
PERC C C
MS -��' off 508-362-4541
MS �'t. Ad-1 c fax 508-362-9880
.70 '��° I .LA. yam A.
DANIEL y�� I downcape.com
1 OYR 6/4 10YR 6/4 o OJALA t o o p
CIVIL � �� down cope engineering, h7C.
o 0 2 � .40980 r,
120" 36.3' 120" 36.3' �o��F SOP civil engineers
NO GROUNDWATER ENCOUNTERED Scale: 1"= 20' � c, an � y
Lp` land surveyors
S�I�v .
939 Main Street ( Rte 6A)
2-043
o 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675