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HomeMy WebLinkAbout0166 OLDHAM ROAD - Health 166 OLDHAM ROAD, OSTERVILLE A= 120 127 a � ° a Commonwealth of Massachusetts ao- ��� W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 166 OLDHAM ROAD m Property Address TYNDALL DONNA G� Owner Owner's Name 's information is required for every OSTERVILLE ✓ MA 02655 02/01/2017 + page. City/Town State Zip Code Date of Inspection r%2 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 �( filling out forms �j�.# /a/ on the computer, 7j use only the tab 1. Inspector: key to move your cursor-do not JOHN P GRACI SR use the return Name of Inspector key. GRACI SEPTIC INSPECTIONS LLC LCompany Name PO BOX 2119 Company Address TEATICKET MA 02536 City/Town State Zip Code 508-641-6694 S11468 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in"the proper function and maintenance of on site sewage disposal systems. I am a-DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑_ Needs Further Evaluatio by the Local Approving\Authority 02/01/2017 Inspector's Signature Date i F The system inspector shal mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 3 ys of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the i spector and the system'owner shall submit the report to the appropriate regional office of the DEP. a original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority.; ****This report only describes conditions at the time'of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. : t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 166 OLDHAM ROAD Property Address TYNDALL DONNA Owner Owner's Name information is required for every OSTERVILLE MA 02655 02/01/2017 page. CitylTown 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: AT TIME OF INSPECTION SYSTEM IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. 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): NA t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 166 OLDHAM ROAD Property Address TYNDALL DONNA Owner Owner's Name information is required for every OSTERVILLE MA 02655 02/01/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or 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): NA ❑' 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): NA C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I °M 166 OLDHAM ROAD Property Address TYNDALL DONNA Owner Owner's Name information is required for every OSTERVILLE MA 02655 02/01/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: NA *"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: NA 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 '/?day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 166 OLDHAM ROAD Property Address TYNDALL DONNA Owner Owner's Name information is required for every OSTERVILLE MA 02655 02/01/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet_ of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ z 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 166 OLDHAM ROAD Property Address TYNDALL DONNA Owner Owner's Name information is required for every OSTERVILLE MA 02655 02/01/2017 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 343.3 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 166 OLDHAM ROAD Property Address TYNDALL DONNA Owner Owner's Name information is required for every OSTERVILLE MA 02655 02/01/2017 page. CitylTown State Zip Code Date of Inspection D. System Information Description: 1000 GALLON SEPTIC TANK .11/4/2016 A NEW DISTRIBUTION BOX AND (5) FIVE LC-6 LEACH CHAMBERS (4) FOUR FEET OF STONE ON ALL SIDES AND (2)TWO FEET OF STONE ALL ENDS. Number of current residents: (3)THREE Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system,inspection ❑ Yes E. No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d TOWN 9 ( Y 9 (gp ))� . Detail: Sump pump? ❑ Yes ® No Last date of occupancy: - OCCUPIED Date Commercial/Industrial Flow Conditions: Type of Establishment: NA NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA 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: NA t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 166 OLDHAM ROAD Property Address I TYNDALL DONNA _ Owner Owner's Name information is required for every OSTERVILLE MA 02655 02/01/2017 � page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: NA Date Other(describe below): NA General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: NA gallons How was quantity pumped determined? NA Reason for pumping: NA 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): &ns.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 166 OLDHAM ROAD Property Address TYNDALL DONNA Owner Owner's Name information is required for every OSTERVILLE MA 02655 02/01/2017 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2016 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: fe e et 1 t Material of construction: ®40 PVC 40 PVC ❑ cast iron El (explain): Distance from private water supply well or suction line: 1 feet Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANKS APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSPECTION. Septic Tank(locate on site plan): Depth below grade: (12) TWELVE INCHESfeet Material of construction:, ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) SEPTIC TANK MATERIAL IS CONCRETE If tank is metal, list age: NA years . Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLON SEPTIC TANK Sludge depth: ZERO t5ins.doc•rev.6116 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 166 OLDHAM ROAD Property Address TYNDALL DONNA Owner Owner's Name information is required for every OSTERVILLE MA 02655 02/01/2017 page. CityfFown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) i Distance from top of sludge to bottom of outlet tee or baffle 34)TTHIRTY FOUR INCHES Scum thickness ZERO Distance from top of scum to top of outlet tee or baffle (6) SIX INCHES Distance from bottom of scum to bottom of outlet tee or baffle 0 How were dimensions determined? MEASURED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): SEPTIC TANK APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS. t Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain): NA Dimensions: NA Scum thickness NA Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA Date of last pumping: NA Date l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 166 OLDHAM ROAD Property Address TYNDALL DONNA Owner Owner's Name information is required for every OSTERVILLE MA 02655 02/01/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NA Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): NA r Dimensions: NA Capacity: NA gallons Design Flow: -NA gallons per day Alarm present: ❑ Yes ❑ No - Alarm level: NA Alarm in working order ❑ Yes ❑ No . Date of last pumping: _ NA Date Comments(condition of alarm and float switches, etc.): NA 4 `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments CGM , 166 OLDHAM ROAD Property Address TYNDALL DONNA Owner Owner's Name information is required for every OSTERVILLE MA 02655 02/01/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert BOTTOM OF PIPE 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.): 11/04/2016 A NEW DISTRIBUTION BOX WAS INSTALLED . DISTRIBUTION BOX IS STRUCTALLY 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.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located, explain why: NA t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 166 OLDHAM ROAD Property Address TYNDALL DONNA Owner Owner's Name information is required for every OSTERVILLE MA 02655 02/01/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: Elleaching pits number: NA ® leaching chambers number: (5) LC-6 ❑ leaching galleries number: NA ❑ leaching trenches number, length: NA I ❑ leaching fields number, dimensions: NA ❑ overflow cesspool number: NA ❑ innovative/alternative system Type/name of technology: NA Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): (5) FIVE LC-6 LEACH CHAMBERS WERE INSTALLED 11/04/2016. SYSTEM IS STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY. NO STAIN LINES SYSTEM WAS EMPTY AT TIME OF INSPECTION, Cesspools (cesspool must be pumped as part of inspection) (locate on 'site plan): Number and configuration NA Depth —top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA NA Dimensions of cesspool Materials of construction NA Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official i p I Inspection Form - c a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 166 OLDHAM ROAD Property Address TYNDALL DONNA Owner Owner's Name information is required for every OSTERVILLE MA 02655 02/01/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA. Privy (locate on site plan): Materials of construction: NA Dimensions NA Depth of solids NA Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA { t5ins.doc•rev.6116 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 166 OLDHAM ROAD Property Address �— TYNDALL DONNA Owner _._... ----- - -- Owner's Name ------ information is required for every OSTERVILLE MA 02655 02/01/2017 _ _ ._ _ _ page. Cityrrown 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 WV- EXISTING SEPTIC TANK 2 4W� 5-Lt-� L.E,AC11 ClIANAB�lSLOA o �nl 4' 64 STONE ALLSIORb 2' of SMME All. ENDS VEAT' • 5 (,6utCik4d) 62 � - A3- Ito u3 5 C3- 23�- A4- 38 -3C�� C4-- 20 A5. 54 S- C5 3A.2 t5ins.doc-rev.6f16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 166 OLDHAM ROAD Property Address TYNDALL DONNA Owner Owner's Name information is required for every OSTERVILLE MA 02655 02/01/2017 page. CityTTown 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: 10+ FEET feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: HAND AUGER Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c�M 166 OLDHAM ROAD Property Address TYNDALL DONNA Owner Owner's Name information is OSTERVILLE MA 02655 02/01/2017 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection-Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater- ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file s r t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r TOWN OF BARNSTABLE N' LOCATION 1 WP OLD NA M Fto SEWAGE# ;-u t b- 3SN VILLAGE 0STERNIWE ASSESSOR'S MAP&PARCEL 120- 121 ALL CAPS INSTALLER'S NAME_&PHONE NO. a�1 ROM E NTA S08 ,�Q 7$(01 SEPTIC TANK CAPACITY 1000 &ALLOW L94Cc 4 5-�.rC: LEACHING FACILITY:(type)S-� P C.WlMOMS (size) NO.OF BEDROOMS 2 TW 0 GPO 4 BEUROW DEQ, (-W OWNER DomNA IYNK)AL-L- PERMITDATE: 1012-1 1201 LG COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted-Groundwater Table to the Bottom pf Leaching Facility 5 Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) P1 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feel of leachin facility) IA Feet FURNISHED BY vlj vl -- r d a O: C L� f O e � 1 Cc� I J O 07 V� JV O� LN `^s OA t�'lOCATION SEWAGE PERMIT NO. LLLA6E INSTA LLER'S NAME i ADDRESS K. S U 1-L D E-R OR OWN ER- DATE PERM-IT ISSUED OAT E C O'MPl1 A NC-E 1 SSUEM, _ 3^ v s S'"�; �� .�., ��s.� iY , .1 � . 1 y 3�,, No. �v Fee 1 UV THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplicatlon for Disposal *pstrm ConstCUttion VPrtnit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Compon Location Address or% Lot No. l u(i MDR," P. Owner's Name,Address,and Tel.No. , °��r. p 20 I2 TM DA LL bo mN A Assessor s Ma /Parcel i r 11 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 505 411531 F. Mt, & V ,> ' s.8-7�-Lalg GIN RIN(T �J 0 oL G NG �'' Type of Building: Dwelling No.of Bedrooms U) TW o Lot Size 115,000 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 220 gpd Design flow provided 3*.4 gpd Plan Date—CAI Oct i 20I(O Number of sheets L2) -rV�O Revision Date ' Title ,1�A Size of Septic Tank Type of S.A.S.(5) LC-4 L"cAr�I 6 CAAAMSIMS Description of Soil w/4'=w a- AL L S I M—s 2,1 o+&+oNE- bN SON SW V3 pjG54Rg 2016 9,21 t g0 o Nature of Repairs or Alterations(Answer when applicable) I A S TA L.L D--BOX NF—yq LEA-CH H RF_u) AS PER "PLAID Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boar o alt Sig Date �0 Application Approved by Date Application Disapproved by Date for the following reasons Permit No.� �� T Date Issued ry E No. ��U !/I 3U ( � Fee?' THE COMMONWEALTH-OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN�OF BARNSTABLE, MASSACHUSETTS Yes 4plicatlon for MispoBal 6psirtn construction VPrmit Application for a Permit to Construct( ) Repair( ). Upgrade( ) Abandon`( )' ❑Complete System ❑Individual Components Location Addressor Lot No. 0(A j O LD H A 11V!' � Owner's Name,Address,and.Tel.No. ' oS1 T, �0 12 T Ym aA LL1 no N A Assessor s Map/Pap/Parcel N Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 50 , 5-3 A7„rsd�n '�'k�rr�ulrl_L.l. s03-37C-La19 ENCINLF FIN U�d�k51N(, Type of Building: Dwelling No.of Bedrooms (2) Two Lot Size 154000 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ).Cafeteria( ) Other Fixtures `T Design Flow(min.required) 22 gpd Design flow provided 34'3. ` gpd Plan Date CA I O(i 20 I(p Number of she Title ets �2 �YV O Revision Date Size of Septic Tank Type of S.A.S.�5) U-6 LER C44 W 6 c WM6L S Description of Soil w l 4 'MW G7 ,A►„L 51 nts 21 o 7 5 o bo OQTVI �_-Nv5 . bGcAF<r 2016 62 Igo o �ii Nature of Repairs or Alterations(Answer when applicable) ! `1V S TA L.L PAX c N L.YI1 LEACH F'(ELP AS PE;g PLAN Date last inspected: x+ 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 f e lth. _ --- - Si, t Date Application Approved by - g. Date Xto /oZ 7/,/ Application Disapproved by Date for the following reasons Permit No. Date Issued 4- -- ----- 12-� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE;MASSACHUSETTS Certificate of Compliance i THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Jy Upgraded( ) Abandoned( )by F-�1\ CAc,,Pe �u�N�2Gr.jW2+J�w at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NoQ216",39-0-Adated Installer 2( w T►i L LN C Designer #bedrooms Approved design flow gpd s The issuance of this permit shall not be construed as a guarantee that the system will hct o a's designed. 11 Date I 1 .t f1 f 1lrn Inspector �� �,L, / 1, ---------- ---- -----------------------------------------------Fee-- / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE' MASSACHUSETTS Misposal 61-p-stem Construction Vermit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at h to O i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be/completedjwithin three years of the date of this permit Date r 4 A roved by tea Town of Barnstable Regulatory Services Richard V. Scali,Interim Director ' B/lFL^731'ABLA,I� i63� 16 g 1 Public- Hea;lHealth :Dii`�isioi ,� £ON a Thomas McKean.Director 200 Main Strcet,Hyannis,NIA 02601 Office: 508-862-4644 Far: 508-790-630 t Installer&Designer Certification Form Date: a 6L, Sewage Permit# Assessor's MaplParcel 17-0 Designer: T= ;vi r ,�,_ i-, C LIS, i Installer: W 1 h 5ioll Jhee�n M Address: 1 Z i ti, C cti ,� ;z fZ�'� Address: On O '_L�' ���-J"� '!;WMG1_was issued a permit to install a (date) (installer) septic system at %645 C1/-,Ag , fV CJ.5 --c.-�z%I based on a design drawn by (address), 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. Strip out (if required) was inspected and the soils were found satisfactory. 1 certify that the septic system referenced above was installed with major clidtiges (i.e. greater than l U' lateral relocation of the SAS or an vertical relocation of any cons � Y p mcnt of[lie septic system) but in.accordance with State & Local Regulations. Alain revision or certified as-built by designer to follow. Strip out (if'required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in con liance-with the terms of the l'!A approval letters (if applicable) PETER T. (Installer's SI 11dlU1"e} McEN1EE CIVIL_ L. No. 35109 esig ler's Signature) (Affix Desig Mere) PLEASE ItETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIF)fCATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. '111ANK YOU. QASepticU)esigncr Certification Fonn Rev 8-14-13.doc Town of Barnstable P# gyp' Department of Regulatory Services e BM Public Health Division Dace - c6 o t63q ti6� 200 Main Street,Hyanuis"MA 02609 rFo�nn'l" Date Scheduled Time Fee Pal �lCI r C� `oil Suitability As;slwssment,f og Serge Disposal PerformedBy:. � � Witnessed By. F LOCATION & GIt N 4 RAL INFORMATION Location,Address / j Owner's Name VI dc, L41 Address. Assessor's Ma cf�sf---V,"i 1 e (vt 14 0 Map/Parcel: f�`7Engineer's P � Name NEW CONSTRUCTION REPAIR t Telephone# :`"a C1��._.'�'-7_7 Land Use `�CA Jt 3`^,0 Slopes(,To) � Surface Stones Distances from: Open Water;Body .51G I Possible-Wet Area�L.5 Drinking Water.Well. L �?ft DrainaOWay ft Property'Lne'6 -_ft Other ft SKETCH;(Street name;dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) is Y �S (:,.4,Al f 4 a LDtm r Parent material(geologic,) S r Depth to..Bedroek Depth to Groundwater: Standing Water"in Hole: o-&A Weeping'from'Pii Pace ram? Estimated Seasonal High Groundwater,' f c�2 r ""'"'"'"'t'�.� �� �� 3-�. �'�✓�-�" DFTrRMINATION FOR SEAS ONAL HIGH WATER TA13LE Method,Used d f dd Depth Observed standing n.obs.hole in; uepth`tu soli rrt0lH4s:_ .. ln, Depth to weeping from side of obs.hole: z in• C3rntindwaier AdJtstment __ i't• Index Well# Reading Date: index Well level, . o,..,; Adj,factor , Adj.Oraundwatet level gg . PERCOLATION TRS!1' Observation Hole# ) Time it:9" Depth of Perc :. -�' ' Time at 6" Start.Pre-soak Time'C� ` Time(90.6 End Pre-soak - Rate Min./Inch; Site Suitability-Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)_ Original; Public.Health Division Observation Hole Data To B.e'Completed on Back----------- **! *I f 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:IS EPTIC\PERCFO Rtv1•I70C JDEEP.OBSERVATION HOLE LOG _ Hole:# � Depth from Soil Horizon Soil Texture $oil Colo?" Soil Other Surface(in,) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency, Y}ravei) -97 & —13 C-t 1�- Ca G r�- 5``f s�% 3 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) Q r. 04. ]DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color -..-Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. C si tency_3o Gnve11_ :DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders., Cons'•ten ° Q[�.y�IL.:._,_ Flood Ins,�uranee Rate Ma- Above 500 year flood boundary No_ Yes _ Witldn 500 year boundary No _ Yes ; Within 100 year flood boundary No.—/, t'es Dept of Natui'ail Occuz"ring�Pervious Material Does.at least foul'feat of 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? Certificatioi I certify that on �U (date) I have passed the soil evaluator examination approved by the Protection and that the above analysis was performed by me consistent with Department of Environmental P the raquired training,a ertise and.experience described in 310 CMR 15.017. i Signature -- :Date Q:\SBPTlC�PSRCF1ORM-DOC YOU WISH TO OPEN A BUSINESS? : For Your Onformation: . .Business certificates (cost$40.00 for 4-years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.--it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL.,.367 Main Street, Hyannis, MA 02601-(Town Hall)_ a I�i'f�� F "'i�r t •R4m: .(. ; DATE: 15 Fill in please: '-;VMh 02401"J APPLICANT'S YOUR NAME/S: �USINES S' YOUR HOME ADDRESS: TELEPHONE # Home Telephone Number - - NAME OF CORPORATION:✓ a 3 u SS p/= /✓v y 7- 3S 3 a� NAME OF NEW BUSINESS TYPE OF BUSINES5S•�iCccG�r 15 THIS A HOME OCCUPATION? YES NO / ADDRESS OF BUSINESS' f(Q 9�� Ds MAP/PARCEL NUMBER % "� /'� / (Assessing) When starting,a new business there are several things you must do in order to be in compliance with the rules and regulations,of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. U7 1. BUILDING CO *1o R'S OFFICE T COMPLY WITF! HOME OCCUPATION This individu ' r of ny , ermit re irements that pertain to this type of buNWsb RULES AND,REGULATIONS, FAILURE TO z Si nat re** = :OM'PL.Y MAY RESULT IN FINES. MMENT l 2. BOARD OF H ALTH This individual has b informed of ermit a uirements that pertain to this type ofMFLY WITH ALL c - HAZARDOUS MATERIALS REGULATIONS ' Authorized Signatur , COMMENTS: - . 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. - Authorized Signature** COMMENTS: Date:DPI WN OF BARNSTABLE r TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM f NAME OF BUSINESS: \Q BUSINESS,LOCATION: INVENTORY MAILING ADDRESS: TOTAL AMOUNT- TELEPHONE NUMBER: G — CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: f_o cam► SIR V T Ip N INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product- Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW USED- — - Any other products with "poison" labels 4 (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): t Metal polishes � (�_.. /2L .,6 Laundry soil &stain removers (including bleach) � r � Spot removers&cleaning fluids woes �� o � 6 (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials commonwealth of Massachusetts Executive Office of Environmental Affairs Etta De artment of RfcEeVfp p• OCr 2 3 ` Environmental Protection �99 Wllllam F.Weld is . Ooyemor Trudy Coxe 8eeratary.EOEA David B. St►uhs CommWicner rV SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: f(0(Q alema C�C�C�j Address- of of Owner: COX �Y� Date of Inspection:/ �//—9S— !� _/ / (If different) Name Name of Inspector/rAz,,rDz J.— �Clr"k�p . �/� Company Name, Address and Telephone Number����awy �/�S OYUQ4y LK 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 se age disposal systems. The system: Passes _ _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails / Inspector's Signature: Date: !eP The System Inspector shall submit a copy of this inspection report to the Approving Authority 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 systern owner and copies seill to the Buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,.C, or D: , AJ SYST M PASSES: 1 have not found an inform ation mation which indicates that the system violates any, of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. BJ SYSTEM CONDITIONALLY PASSES: . One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND), Describe basis of determination in all instances. If"not determined", explain why trot) The septic tank is metal, 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 conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 e Telephone(817)202-SSOp ��Printed on Recyelyd Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: t'(' 9hal?� UCc�1 S\���U� //e Owner: � Date of Inspection: Q�-- e] SYSTEM CONDITIONALLY PASSES (continued) 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 i more than four times a year due to broken or obstructed pipe(s). The system will pass The system required pumping Y _ Y q P P S inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed CI 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 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. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The cvctem has a septic tank and soil absorption system and is within 100 feel to a surface water supply ui tributary to it surface water supply. _ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and 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• D] SYSTEM FAILS: r more of the following I have determined that the system violates one o 6 failure criteria as defined 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. 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. (revised 8/15/95) 2. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . / ^lld�G CERTIFICATION (continued) .// Property Ma—AVS ess:.A (� V O d, C)i`� Owner: Date of Inspection: D]SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6" below invert or available volume"is less than 1/2 day flow. 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 I 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. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 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: 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) ora'mapped Zone II of a public water supply well).. The owner or operator of any such system shall bring the system and facility into full*compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 it SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: /(x, �� �s v Ae Owner:0_)x,-/`l$ VCf le-?V,1X Date of Inspection: /6 Check if the following have been done: L-15-timping information was requested of the owner, occupant, and Board of Health. ✓Flone 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. L'�As built plans have been obtained and examined. Note if they are not available with N/A. t/The facility or dwelling was inspected for signs of sewage back-up. t/the system does'not receive non-sanitary or industrial waste flow t-The site was inspected for signs of breakout. "ll system components, excluding the Soil Absorption System, have been located on the site. vThe septic tank. manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. t-The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. �e facility ov ner (and occupants, if differen! frcmn owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. } (revised 8/15/95) 4 SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Na//&s ess:16(e Oldham �` O a C�J QS lew�Ile Owner: Date of Inspection: 16 FLOW CONDITIONS RESIDENTIAL: Design flow: Z W Ballons Number of bedrooms: Number of current residents: oZ- Garbage grinder(yes or no):27{j -- Laundry connected to system (yes or no):_2°6 Seasonal use(yes or no): Water meter readings, if available: Last date of occupancy: COMMERCIAUINDUSTRIAL•: Type of establishment: Design flow: aallons/day 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 PUMPIN ECORDS and source of information: System pumped as pan of inspection: (y s.or no)ZVO If yes, volume pumped: gallons Reason for pumping: TYPE OF M 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) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or noj (revised 8/15/95) 5 �I • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: A0 69 Owner:(2/kzr/es (blew o4p" G Date of Inspection: SEPTIC TANKY_ (locate on site plan) Depth below grade: Material of construction: 1.rrcrete _metal _FRP —other(explain) Dimensions: Sludge depth: C2 _ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_ 6 0 Distance from top of scum to top of outlet tee or baffle: /i Distance from bottom of scum to bottom of outlet tee or baffle:_] Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structura integrity, evidence of leakage, etc.) QiZ /O60 e-c 4. ' le- i Q ' a s GREASE TRAP: G -.LV IA (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom nt «ism tr, bottom of outlet tee or baffle Comments: (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.) ed B 15 6 Irevis 95)/ / SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property6,`dress: Owner. �=i7Ql/ems Date of Inspection: TIGHT OR HOLDING TANK:QY/ (locate on site plan) Depth below grade: _ .4 Material of construction: _concrete_metal_FRP—other(explain) Dimensions: s Capacity: gallons Design flow: gallons/day Alarm level: 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: K_k5/1f1._4CA } Comments: (note if level and dstribu!io^ is equal, evidence of solids carrvove', evid ce of leakage into or out of box, etc��S7�/`„��a COG/-�Y�� Aa ci f cLv� �i G �7���-e PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments:. (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised ti/1S/9s) a'. ' t . , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: �Co�D Owner: Charles Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: - - Type: FIp-d i 796SS0/S - o� leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number. omments: (note condition of soil, signs of hydraulic failure, level of pondin ondition of vegetation,etcJ r'� a,,- CESSPOOLS: (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 (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- �- (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 8/15/95) 8 , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: Owner: Date of Inspection: _ SKETCH OF SEWAGE DISPOSAL SYSTEM: . include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' s +f say Y r DEPTH TO GROUNDWATER / Depth to groundwater: /�6 feet ,/ method of determi ation or proximation: /2",j"i/i? I'�3r�1 ///, .5' 4- O 7 _04�91, o c tsar (revised 9/15/95) 9 /-J TOWN OF BARNSSTABLE LOCATION/ e /L�' nQ l SEWAGE # I /ao VII,LAGE nr-9 f 2e ASSESSOP MAP&LOT /Q NAME&PHONE NO. � SEPTIC TANK CAPACITY LEACHING FACILITY: (type) )c:I!) S l / (size) NO.OF BEDROOMS BUILDER OROWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility hr 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 fwA of leaching facM�%AUC4,aa Feet Furnished by �� SING. 1 YJ� O , - 4— F�$... .................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .......OF.... ?. - ...................................... for Uhipniittl Vorkr, T omitrurtion ramit Application is.hereby made for a Permit to Construct ()k) or Repair ( ) an Individual Sewage Disposal System at: _ 1 U ---------•---..........------- ..................... '? .Location-Addr ss i Owner Address ............................ ......• . Installer Address dType of Building Size Lot. ....: .......Sq. feet V Dwelling—No. of Bedrooms___..._.�.............................Expansion Attic ( ) Garbage Grinder ( ) L . No. of persons............................ Showers — Cafeteria P4 Other—Type of Building _. dim ' _. ____.__ p 1 (� ( ) Other fixtures -----------------------•---------- Design Flow.......h_.f ............................gallons per person per day. Total daily flow......... ............_._..._..gallons. WSeptic Tank—Liquid*capacity!LVO..gallons Length- �.�Width__�I.jo _ Diameter................ Depth_-s r... x Disposal Trench—No..................... Width_...___. ........ Total Length.................... Total leaching area..__.......•........sq. ft. 3 Seepage Pit No.................... Diameter......__l�___.__._... Depth below inlet................ Total leaching area.��4....sq. ft. z Other Distribution box ( ) Dosing ..a Percolation Test Results Performed by...__. _!1Xrl fX ,.. !C? E^ ! ----- Date...LL!/8 _----_ aTest Pit No. 1---4..Z,.0minutes per inch Depth of Test Pit___iZ.......... Depth to ground water Test Pit No. 2--..�/!_minutes per inch Depth of Test Pit---2 ..... Depth to ground water__Ill-✓?!-._--_--- fYi ----- --•-•-----•---•-•--•---.•---- -- ------- - Description of Soil-------------�. _`__�..��L.....-- .�(.....+_... 6 P C-!'- ....----------------=-----------------------•---•--•------•-----. x ! �J. bGa-h7. G�,. (� --- -•••••-. - - ------------------ ..... 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 iITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.z - . ...... .-•. ..... . Date Application Approved By----•---- '�= .. l .�i ._...._._._ Date Application Disapproved for the following reasons----------------------•-•----------•----------------------------------------------••-•...-- ----------....._... ....................•-----.......-•-•-------------•----•------------------•-•----•-•-------••---------------------------------------------------------•------------------------------------------------- s. Date PermitNo..................................................•------ Issued_....................................................... Date ;:t:p THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) M A�-C&F DATA •�^ /�•- fL r� � � 7 Fizz.. . _..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF (HEALTH ...............OF...:� �- :.... �> r:_..- Apptiration for Uiipoual lgorkii Tou.5trutrtion ibrutit Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal System at: l - ... ///),� ``,\\ t`•1 Location-Add r ss 1 1 or Lot No. (/�r Y �..-..0:`.:..2.1...--� w•"1: a• C w .. . ......... i yOwner Address ........................... ---------------------------------------------------- --------•--•---__-________--_-----•--•----:____-•------_.____-_______----------------------•-_--_ Installer Address dType of Building Size Lot.]_ ,_ -'........Sq. feet U Dwelling—No, of Bedrooms-_-____.._ _ Expansion Attic ( ) Garbage Grinder ( ) ----------------------------- p'�., Other—Type of Building -l? . _�j-,........ No. of persons____________________________ Showers (Z) — Cafeteria ( ) 04 Other_fixtures ............................ - - . •••• W Design Flow____.__h-�...............................gallons per person per day. Total daily flow.......... r_ ______. _-______.___gallons. 9 Septic Tank—Liquid capacit}6OZ?-__gallons Length.O`&'..'. Width_! .h2.._ Diar-leter;-:_--:__----__- Depth__!...'t Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area__-____....___......sq. ft. Seepage Pit No------ ------------_ Diameter......G_...--_._. Depth below inlet___,.4�......_... Total leaching area_7-_t._�.___sq. ft. Z Other Distribution box ( ) Dosing tank ( ) -. r- '-' Percolation Test PiTNoestR l su/S_:?..,�gninutes Performed r nch...... De Depth of 'Test Pit__^�.-`.�_._..�. Depth toDaound water4��_:_r� (� Test Pit No. 2.... minutes per inch Depth of Test Pit__--1$/���_____ Depth to ground water ;ell ____.-. a �-----•-•••••--------•-----••-••-•••••-•-•••--••-•...............•--•-------..__...------..._._...------•----•--••-•-----...----•----•----- Description of So>l______________f� ' ire ..__ ;� U i :..? r 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 TiTILE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed-- Date thrApplication Approved By........ ..._ --•--•-•--•--••••--••---•-••--•-- t Application Disapproved for the following reasons: -------------------------------------------------------------------------------------------------------------- --•.............•••-...-•----•--•----••••-•--•••---•---•-----•••-••--•••--•---•••--------.....•-•--•----- Date PermitNo.......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .OF. -w : .. 1..��� .:,r....................... Trrtifiratr of Toutpliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by =.... :__....- ----•----•-------------•-----........--•---...----- ---------- == e� +L Installer -1 Z.has%een installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._ ! .r ______________ dated.................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. D,,ATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH w, •.�...,�...............OF.......��� - :;�};..�'•.!•-�7_....�.- FEE._V-.....°°�--.... •-�-•�iu�ou�al ork� �oatu�riori rruti� Permission is hereby granted....... !__ _______________ _ __-__--_-_-_____-_ to Construct ( y� or Repair ( ) an Indiividual Sewage Disposal System at No....'._._ •=..F.:_, t; -r, t:'-:-; ... �,? 'rl-r<_v Street as shown on the application for Disposal Works Construction Permit No..................... Dated._._____.---.--.__._____._....._._..._.... _ ----------------------------------------•--•-----____- DATE. � /_ �Y � Board of Health ............ ---- -----••------ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS IVo,TE : JR TNe� SFPT/G T�1 N/Y /S MORF /iVCNE;"S BELOi4I 4R.+1DE, A 24 �/Q'FT A•1Y/1/ T /NCH DIA14ArARR CoNC,rET.G CO✓8R S1pV.49L RA 4'•PVG P/PE BE8ROU6NT TO G= O�, �AN EXTRA /yFi4YY G'ONfRETE M/N:PITCH CAST $//.44LL BE US.I�O 1F /N L o z,.3 COVERS /BPER FT- DR/✓EWAy t; o 2J:MIN, 4PTA PERF'ORAT� P1�t P/PE LIQUID LEVEL �— CLEAN -SAND --�� • 5' a ,o_oS� G'AST` 917•9 "� /RoN PIPE l d o O +a' GAL. •,::'.::;•:'; �:.: :;,:t: .:Z, /-1hV P/TCN D/ST. t Est"ter SEPT/G: `TAN/C •. .,.. LZACH/NG ,FIELD AVOKB C TASIIJ-A7 N� o• X, S,EGT/ON OF.: GROZIND 1MATiER 7A$LE x, SEWi4GE DISPOSAL SY37E/�! Ts4BllL•4T/ON . a ' X . t •_ L.E.4CHING F/ELO . D/��Nslo�r A 3 Fr. s 8CAL8 Yo~ -S.,/ � Q~ O/NENS/ON - ZiT 3 FT 6 FT o c .x F w .K w F«G L'•.e .nA �i �° O/M evs/aJv C �' ': "§ `t$r::7: •.. , :!. i .: ..�'6 r.., r:�' ..„+i'�- x 3-6:..G�"L/v�/ t t•urE� , _ �pDoue�E 43 z@ SOl,L zLOG'` s 7 OF=t 3 •• p1rRFlARATE ,,Y =k +�` SA/L TESTS' ..S'B/LTES7�` 2y: 1 �:w t a �� at•, / a, F :{ yEDS7t�NF /SIC P/PrE DATGt'Oh' r` G%moo/Zv 1� 1E��t1tTs D, il� r 'e4lo AJ�G P OtIlT! N'RATd' i'- • aEyR� ,..:• .:7 ►.. ''.'_ PGI� �/I p r�. - .�. r; - `C. }z 5.:+•.,:4 D y • - (. _.r x t `4A S w '_.. "La^S•••far:S• Cn •aea•1'`�`L�(LQ.TD 237 • '+ :... .' .',•_. >... r:,• .i.,` '+4` �,aGC.„e _ ' a .. •` , ..;: :L _•m :,7:t.. ,, .. .,., .-..- _.. . .::... .... ;• . .,;>, ,��� � ? :DEaSIGI{f "CRl TER`J� � r _ , /�y •� .. .r •• •. .+,•.• •- S. .. 'no t 4s .r,r t.}. .., t.� .t -v• /:✓. ':i�F k'r`:•;c°$s •i•+ _� c4G"O1DL�► . 4 =/ �j /VUM�ER CP' BEDRDOHS yvAsy1��.9T O N c PFfiF�ITF�7 ONffT 8 FT G4R A/ AL U!V/T W. 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I�':1 'any 3 t4c� .ti , 1, t O� r t a.: a t; f u� �r z��'rr j u t'k t ' :�' y �� _ < x._y {rr �� r r a t s_l f yrx y �'7" �LZ r r _' ; .1 ri,, �j']'�� f`�'' �-i 1 e, 3i M" r t r z r T r S ;Lf y ; .:.�- a z .: rf I. j�, r. `t i z t T „., t y y ik k.. r c }Y' t f ° yes ,, ;fi rE, .p Na 29874 4 .s r L 'a+�t '�39 �4._. ,E X-�ify �F. x I:ym,tx t J�E], z i �„ ,+ a y , C� , ,k t k ;`,„•}41 'j�+ a"F"L '`� �'r.A t' '� t( t " �-0 IF:: .1 i t e rp Ij x 7'.r °% t+•,.,�,,«, t 1 ss4`+ 1r K,K'�y �f�z,Ex f +x : w'`t t: ,c z r' x � .` - + r`.''t x r d a=.rE r ng...r i>la a� rE C + !t1 'FPS 11 a?t{f ��'SuR M 9 'i ,iy .., cL E K /. 3Y •Y".. 4. -4; N, J'.+ f„ r (' r4 i :r r r`.:t �� , kw �? .S C d -F {,^eT�r ,a� d, E+ 1'� w c, '. .. .. .. . ;j, li, � OtlI�O �.UPCT ELZ-vAtto t ?a !,I; § ���A�tTo s CERTIPIE� PLOT. Pl.l�� 1'01971 a r.�CNT0�1R +,.m, . ►� ..r..:... Y °7? ale � ',i ,a3 q� s 1. j,itWa At`3�RT �� /.p''T ; $/ :QL /U' va -* 03tt Sf1�D EROT. �LLf/�f?t00 x' "I p, �: s f , : �. t IF, t SPOED C NTOU , 1!t-p .!,., .; X. f .. e.... ., 1 I/l �� e ...�..rij �....... r ;►/ s .',1(:-,A S x t t i y�t�_v, r it 1s,(�a�M/O f 9�J1�Q 4 `a t ,:,. k i % .: j . .rtr .,. iI.c z r `` --.ti a� e a s 'T i''L ff` s''�,- q©i�_ ,�/��1�1 �\ .s1 �Al.a Fu Sys k y:S E't ".•jC�µ, f'fYR3`r 5'� , , F. i i "A' L ATE, ' i ill' OET TY }> i'1�1 � �{ ¢f. �#O�lL� rlo �iATL F� 4` . .— i11 1. 1 s >' t I. 1 C 1@1'I V: 'I'HAT,1 . ;THE PROP�SE<! ' r .. Q;TE ',; REOf9 .�tEt1: i,; O0'� O `rid D 4, ;' 1lfitDINGI iwOWPD ON TN18 PL AiG �'r :�lif#k.: �} r' t 'Rta11� r „Y „ ci1NPORI � To:.l"HE Z®IOIN® �A{ � A �',t 1 WSJ 1 P z E ♦T /x� A �1 t. r . ' :, ?u-F�2/aM♦►'Ap,I.—i'+` .—-�@jFr�n to'�F�X �y''�4' _ { ! ' ° b� .at/�� .� (1.� 'y b ,,,, ni 1;,M�itl 1� 1 r7'j.�"� 'Vz.�Ia�,}j t t +' A� .�, 11 if �,CJ. y a r �> h ' ' , Tt L 'Ni! URYEYOI .., .. nx._ .. r 4..wawus.iti1�.f, v .,_.. ., X.. K.. LEGEND EXISTING CONTOUR N wood X 100.98 EXISTING SPOT GRADE do a ° -W EXISTING WATER SERVICE �c S -t; EXISTING GAS SERVICE p - U UNDERGROUND WIRES c�O v°c co 2 o hii �o`o LOCO TEST PIT � c� BENCHMARK ti• o m ° 5 �a fi Poo c �o � eUmPS �O � River caa\. ROoy -o LOCUS MAP NOT TO SCALE? JOBY- S LANE S 54'26'03" W y 100.00' LOT 51 15,000 ±SF MAP ID: 120-127 1J L 2 4.7 8 �, 24.08 + 25.95 / /< 15' T ___,t34' O / EXISTING S.A.S. (APPROXIMA TE) VENTp3PROP SED S.A.S. O O '9 < O , \ TO BE ABANDONED cn I .- '•1 \� XISTYV62SEPTIC TANK TP_2_:', �/ +,23.13 TO,\OF TANK, EL.=22.2 W cn j 1NV.(OUT)=20.8t(VERIFY) 1 Q ,. 4 y v o .00 24.06 q/b cn „ 0 cn BENCHMARK m 24.15 x x -- x 23, 2 •22.00 o w I CORNER/BU_LKHEAO 22.96 --'�\ p EL.=25.27 DECK \ c 21,79 21,41 °i \ 24.7 24.45 U EXISTING o • \\ x GARAGE HOUSE(#166) �, \ x 22.3 T.O.F.=26.25E \ 25.26 25.40 x 2L99 \21.39 25.16LIT) ' ` G x• 21.11 N x 22.98 .. . \ x 25.64 a.; &01 100.00' 2`3.3 x3, 7 \ Rl' J \ S 54'26'03" W 1 x 24.78 x 29.40 28a5 29,57 24.75 SIDEWALK 29.30 28.40 27.37 edge of pavement 24.53 OLDH' AM ROAD \0 0 F Mgsx o� PETER T. PROPOSED SEPTIC SYSTEM UPGRADE PLAN McENTEE CIVIL N 166 OLDHAM ROAD, OSTERVILLE, MA No. 35109 0 9£ Prepared for: Donna Tyndall, 1431 NE 32nd Ct, Pompano Beach, FL 33064 G/SZE�' �� OWNER OF RECORD Engineering by: SCALE DRAWN JOB. No. TYNDALL, DONNA A Engineering Works, Inc. 1"=20' P.T.M. 201-16 1431 NE 32nd Ct. 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET N0. POMPANO BEACH, FL 33064 (508) 477-5313 9/6/16 P.T.M. 1 Of 2 l NOTE: TO PREVENT BREAKOJT, FINAL GRADE SEPTIC TANK SHALL NOT BE AT, GR BELOW, E'=20.7 FOR A DISTANCE OF 15' FROM THE EDGE INSTALL RISERS & COVERS OVER INLET & OF THE PROPOSED S.A.S. OUTLET AND SET TO 6" OF FINISH GRADE PROPOSED D-BOX PROPOSED S.A.S. INSTALL RISER & COVER INSTALL RISER & COVER OVER ONE CFHAMBER(MIN.) SET TO 6" OF GRADE AND SET TO WITHIN 3" OF FINISH GRADE TO SERVE TLF.G. EL.=212.3± 25t AS AN INSPECTION MANHOLE. F.G. EL.=22.2f F.G. EL.=25.0t F.G. EL.=24.5 to 26.3± CHARCOAL VENT A , L = 22' 1740 t 7' ® S=1% (MIN.) % (MIN.) 4"SCH40 PVC PVC 6' io"t " ®�® TO 1/2RDOUBLEB" . �a" 12" 'MASHED STONE EXISTING 48" LIQUID OR APPROVED FILTER FABRIC) LEVEL ADD J . PROPOSED 4' 3' 4' INV.=20.57 Gas BAFFLE D-BOX INV.=20.40 3/4" L 1/2" INV.=20.80t INV.=20.20 EFFECTIVE WIDTH' = 11' DOUBLE WWASHED • DB-6 SHOWN STONE 3 OUTLETS (MIN.) USE 5 LC-6 LEACHING CHAMBERS IN SERIES EXISTING SEPTIC TANK H-10 WITH 4' OF DOUBLE WASHED STONE-ALL SIDES . 2' OF DOUBLE WASHED STONE-ON BOTH ENDS NOTES: H-20 RATED 1) CONTRACTOR SHALL VERIFY ALL EXISTING PIPE TOP CONC. ELEV.=21.0 _M- ON -BREAKOUT INVERTS, PRIOR TO INSTALLATION. INV. ELEV.=20.20 ER EA EA O a EA ELEV.=20.7 2) D=BOX SHALL BE SET LEVEL AND TRUE TO GRADE ®®®®®® A MECHANICALLY COMPACTED SIX INCH CRUSHED BOTTOM ELEV.=19.20 STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). 2' 5 x 6' = 30' 2' 1 4' OF NATURALLY OCCURRING , 3 INSTALL INLET & OUTLET TEES AS REQUIRED. - ) Q PERVIOUS MATERIAL EFFECTIVE LENGTH - 34 i 4) CONTRACTOR SHALL INSTALL A GAS BAFFLE ON 5' (MIN.) ABOVE G.W. THE OUTLET TEE. ' LEACHING SYSTEM SECTION ESTIMATED HIGH G.W., EL.=14.0 = SEPTIC SYSTEM PROFILE GENERAL NOTES: SOIL LOG 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL DATE: AUGUST 26, 2016 (REF#15,139) BOARD OF: HEALTH AND THE DESIGN ENGINEER. SOIL EVALUATOR: PETER McENTEE PE(SE#1542) WITNESS: DAVID STANTON R.S. HEALTH AGENT 2. ALL WORK AND MATERIALS SHALL CONFORM T THE REQUIREMENTS ELEV. TP-1 DEPTH ELEV. TP-2 DEPTH OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE ••� ' LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: -310 CMR 15.405(1)(b): 25.3 A 0.. 25.0 A 0 1) A 3' variance to the 3' maximum cover requirement, for 6' LOAMY SAND LOAMY SAND maximum cover. S.A.S. shall be H-20 and vented. 10YR 4/2 10YR 4/2 .3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 22.8 B 6" 24.5 B 6" TO INSPECTION.AND APPROVAL BY THE BOARD OF HEALTH AND. THE MED. SAND_ MED. SAND DESIGN-ENGINEER.-- - _ _ __ 10YR-5/8 10YR 5/8` ` - - 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 23.3 C1 24 23,2 C1 22 FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN, PERC ENGINEER BEFORE CONSTRUCTION CONTINUES. 34"/52" 5. ALL ELEVATIONS BASED ON AN ASSUMED DATUM. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF , THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF MED. SAND MED. SAND HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. 2.5Y 6/6 2.5Y 6/6 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. s 8. THERE ARE NO WELLS WITHIN 150' OF THE PROPOSED S.A.S. 4 9. ALL AREAS CLEARED FOR CONSTRUCTION SHALL BE RESTORED AS 14.0 REDOX = 136" 14.0 REDOX = 132"1 AGREED UPON BY OWNER AND CONTRACTOR OR AS OTHERWISE C2 SILT LOAM, C2 SILT LOAM DIRECTED BY THE APPROVING AUTHORITIES. 5Y 5/3 5Y 5/3 13_8 138" 13.5 138" 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY PERC RATE <2 MIN./IN. "C1" HORIZON THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING HIGH GROUNDWATER 136" (REDOX) CONSTRUCTION. 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS IN THE AREA BENEATH AND FOR 5' ON ALL SIDES OF THE S.A.S. AND __ REPLACE WITH CLEAN SAND AS SPECIFIED IN 310 CMR 255(3). ( 4'4" -OCcour 12. AREAS REQUIRING STRIPOUT OF UNSUITABLE MATERIALS SHALL BE I 20"oW COVM INSPECTED BY DESIGN ENGINEER PRIOR TO BACKFILL. I I 13. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY AND - n IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY. I+�KNocKour +'KNOCKOUT f I L------. 4'KNOCKOUT J DESIGN CRITERIA 72" PLAN VIEW NUMBER OF BEDROOMS: 2 SOIL TEXTURAL CLASS: CLASS I DESIGN PERCOLATION RATE: <2 MIN/IN ® ® ® 0 _ 22' ® ® (0.74 GPD/SF LOADING RATE) DAILY FLOW: 220 GPD IN 2Rr I ® ® ® ® ® ® ® I I I DESIGN FLOW: 330 GPD GARBAGE GRINDER: NO r 72" T r" 36' LEACHING AREA REQUIRED: (330 GPD) = 445.9 SF SIDE VIEW END VIEW .74 GPD/SF WWIIGAGIN LC-6, H-20�1LAOAI,DIING EXISTING SEPTIC TANK: 1000 GALLON CAPACITY LEACHING CHAMBER PROPOSED DISTRIBUTION BOX: 1 INLET, 3 OUTLETS USE 5 LC-6 LEACHING CHAMBERS IN SERIES PROPOSED SEPTIC SYSTEM UPGRADE PLAN WITH 4' OF DOUBLE WASHED STONE-ALL SIDES 2' OF DOUBLE WASHED STONE-ON BOTH ENDS 166 OLDHAM ROAD, OSTERVILLE, MA SIDEWALL AREA: (11.0' + 34.0') x 2 x 1' = 90.0 SF Prepared for: Donna Tyndall, 1431 NE 32nd Ct, Pompano Beach, FL 33064 BOTTOM AREA: 11.0' x 34.0' = 374.0 SF Engineering by: SCALE DRAWN JOB. NO. ' TOTAL AREA:........................................................... 464.0 SF;' Engineering Works, Inc. N.T.S. P.T.M. 201-16 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET NO. DESIGN FLOW PROVIDED: 0.74 GPD/SF(464.0 SF) = 343.4 GPD (508) 477-5313 9/6/16 P.T.M. 2 Of 2