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RD - Health _W.BARN� ROPQ OST. 44 OSTI V A=120-WAS V�111111'1�1/� l'11'tf TT7 J, A A as NO Ovri ,n XT tfA, % W Aw"k NUN �ft 4 'JA Pl, P"iIN l",l. -till -P� �,U 1N g vi f��j % A V �,%ifft '3ji -x avwp IT'i", V, ART NY A MWWO sim Nil A to K "4" K -0, fn 060. _:Q two ng oil Pvh A C',f qqEyy ,4"PI, lotq Mf Ty �i ('-�-,�, �,JCW A '. !�� Mimi I IN 'W, Rh M, -Elm mm% 'Lim, W .49, rTIV �,vu 2 v "o gm Is R,W" If oil Am WIN M 59 R wg P-1 in M 4�11 WER Nvw ,12lir 1 71419 14 ipr �4M A # all I OWN ;T,27vaii ii i q'i 10 01 ON f f "!X-4 PTA IONA N�l I I TPF pug V at IT111 PA RA M p's t v�Sap WA 0 f�lfNll:11� I fol� NOR- 40 -low I JR4 tt,'�Ppv"�".Z1115, xg ,i7g� �in, p oft .......... ,fz� tt A #-1 a .ff"!!4 dd�, -i�,A' j4 Commonwealth of Massachusetts Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 44 Osterville West Barnstable Road V Property Address r David Duckworth Owner Owner's Name information is Osterville ✓ Ma 02655 8-21-19 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information filling out forms on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return key. Company Name 374 Route 130 t Company Address Sandwich Ma 02563 City/Town State Zip Code rxm (508)47T_t?65$_,_ S113747 Telephone Number License Number .f. -B. Certtification . Y - F I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1-have personally inspected the sewage disposal system at the property address hst-_u abc*,re; the information reported below is true, accurate and complete as ofthe time of my inspection;,.,,^ .d the inspection was performed based on my training and experience in the proper function and maintcrTI -n-ce of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. FM Passes 2. ❑ Conditionally Passes 3.. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey o m'.,� %o°o am.,.�,w�,.....o 8-21-19 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 1 ' c Commonwealth of Massachusetts �a Title 5 Official Inspection Form �= I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Osterville West Barnstable Road Property Address David Duckworth _ Owner Owner's Name information is Osterville Ma 02655 8-21-19 required for every y page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: The system was in working order at the time of inspection. e aA1 2) System Conditionally Passes: r , ❑ One or more system components as described in the"Conditional Pass"'.sect,*n need t0��,---- replaced or repaired. The system, upon completion of th&,replaceiW or repair, as approved b 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 1� r TOWN OF BARNSTABLE LOCATION &PI XI-liie SEWAGE # q�" y 73 VILLAGE (JSfPr,, ;Ile ASSESSOR'S MAP&LOT LJ0-b Y -QQ INSTALLER'S NAME&PHONE NO. Sohn A a-//9 SEPTIC TANK CAPACITY /S0 b # J LEACHING FACILITY: (type) (size)a" `��L X y'W X a NO.OF BEDROOMS 3 BUILDER OR OWNER G Rdr-�z c D PERMITDATE: �/'�� J/7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Watef 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 P- 3 I Aal �y s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Osterville West Barnstable Road u- Property Address David Duckworth Owner Owner's Name information is Osterville Ma 02655 8-21-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): �f ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 i r 9 c� Commonwealth of Massachusetts r Title 5 Official Inspection Form 13 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Osterville West Barnstable Road u� Property Address David Duckworth Owner Owner's Name information is Osterville Ma 02655 8-21-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I %I Commonwealth of Massachusetts �d Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 44 Osterville West Barnstable Road Property Address David Duckworth Owner Owner's Name information is Osterville Ma 02655 8-21-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No 0 El Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 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 water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ El 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2618 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 44 Osterville West Barnstable Road Property Address David Duckworth Owner Owner's Name information is Osterville Ma 02655 8-21-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. ,� h f h following for all inspections: 6. You must indicate yes or no for each o the ollo g p Yes No ❑ 0 Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? ❑ El Has the system received normal flows in the previous two week period? ❑ a Have large volumes of water been introduced to the system recently or as part of this inspection? El ET available as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ 0 Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? El ❑ 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ Q 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts �d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,v 44 Osterville West Barnstable Road Property Address David Duckworth Owner Owner's Name information is required for every Osterville Ma 02655 8-21-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 Number of bedrooms (design): Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330/GPD Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes [j] No * " Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) .Laundry system inspected? ❑ Yes No Seasonaluse? ❑ Yes [E No See below Water meter readings, if available(last 2 years usage (gpd)): Detail: ***2018- 263/GPD 2017- 139/GPD*** Sump pump? ❑ Yes ❑■ No Last date of occupancy: Nov. 2018Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 r cam, Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 44 Osterville West Barnstable Road Property Address David Duckworth Owner Owner's Name information is Osterville Ma 02655 8-21-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ `!P:s ❑ N Water meter readings, if available: a + "j Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Osterville West Barnstable.Road Property Address David Duckworth Owner Owner's Name information is Osterville Ma 02655 8-21-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 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): Approximate age of all components, date installed (if known) and source of information: 9-16-97 per COC Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 21611 Depth below grade: feet Material of construction: ❑ cast iron Q 40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5ins .doc•rev.7/2 612 0 1 8 p Title 5 Offiaal Inspection Form:Subsurface Sewage Disposal System Page 9 of 18 P Y 9 c � Commonwealth of Massachusetts Title 5 Official Inspection Form i- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Osterville West Barnstable Road Property Address David Duckworth Owner Owner's Name information is Osterville Ma 02655 8-21-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 11611 Depth below grade: feet Material of construction: K 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 1 Dimensions: 500gallons 311 Sludge depth: 3311 Distance from top of sludge to bottom of outlet tee or baffle 0" Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Osterville West Barnstable Road Property Address i I David Duckworth Owner Owner's Name information is Osterville Ma 02655 8-21-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: NAfeet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 c Commonwealth of Massachusetts I , Title 5 Official Inspection Form r^ 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Osterville West Barnstable Road Property Address David Duckworth Owner Owner's Name information is Osterville Ma 02655 8-21-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 III Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Osterville West Barnstable Road Property Address David Duckworth Owner Owner's Name information is required for every Osterville Ma 02655 8-21-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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 i * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: (4) 40'x4'x2' n leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Osterville West Barnstable Road V� Property Address David Duckworth Owner Owner's Name information is Osterville Ma 02655 8-21-19 required for every pzge. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. No evidence of past back up was observed. 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): NA 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form w� IaJ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Osterville West Barnstable Road Property Address David Duckworth Owner Owner's Name information is Osterville Ma 02655 8-21-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Osterville West Barnstable Road Mv� Property Address David Duckworth Owner Owner's Name information is Osterville Ma 02655 8-21-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 srYl taa t `�#-«% t'1 A!sS ;`S8"01~S M &LOT SEPTIC I'v TANK. C.AIPAc r k L,IE�rA.�I11N�x 11 r�CL'�� '�s: (rY ?'��d�' "...."- Lsis.ej�".`�!'�}"d :aC'�'.-'a•�'Jt..Z .81JU..DE 13 6,'4' 1T:'.12 aree��xmLir�z►:T3sssariti�etw�cetx the. iw�t:ax'trntstaacri:A�it�'ccT Gaoxsncivvsi2er�'situ'e;uad F3i�rir��xs:rrf'i..e�c#ix#�FaciYty F f'ri stet tis+'accr SiApply Well and Leaching 1 ac ility .C�ax y wets exsst.. crra site ear wii2t P 2t3U.€ect+�f icachSng taciiity.3 — e ge of W'tttattxti::and t c�cttin 'Facility(lfany wedanxi4 c just-. withi ` t3Q fesiFcif.thing f�i ilicy) t "`� trby f„; — y t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 .a Commonwealth of Massachusetts Title 5 Official Inspection Fora, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Osterville West Barnstable Road V Property Address David Duckworth Owner Owner's Name information is Osterville Ma 02655 8-21-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope ■❑ Surface water ❑00 Check cellar ■❑ Shallow wells Estimated depth to high ground water: No GW @ 12'feet Please indicate all methods used to determine the high ground water elevation: LA. "� El Obtained from system design plans on record 9-16-97 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: A plan on file at the local Board of Health was used to determine high groundwater. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 i c Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 Osterville West Barnstable Road Property Address David Duckworth Owner Owner's Name information is Osterville Ma 02655 8-21-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. B. Certification: Signed& Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed Fo D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included * t5insp.doc•rev.7/26/2M Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 1 /a b v5/G oc�� No. Fee /ad THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Migpogal *pgtem Congtruction Vertnit Application for a Permit to Construct X Repair( )Upgrade( )Abandon( ) X/Complete System ElIndividual Components Location or Lofo. # �I.yv „y� — jl� Owner's Name,Address and Tel.No. ,ij, Q Assessor's Map/Parcel /VQ v/ ooa a WQIY�55 1 - 6QV Q�C• � i� Installer's Name,Address,and Tel.No. F ddl igner's Name,Address and Tel.No.s(+� r B 93?T W,2-0 9T Type of Building: Dwelling No.of Bedrooms Lot Size s . ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ,Z,) Cafeteria( ) Other Fixtures Design Flow 130 gallons per day. Calculated daily flow 6 gallons. Plan Date Number of sheet evi ' Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this ealth. WT Signed _ - Date Application Approved by Date Application Disapproved for the following reasons Permit No. 77 — Y 7 *!1 Date Issued V � '�.. � a �. :�� - � �;-=� dad No. � � �� Fee y THE COMMONWEALTH OF MASSACHUSETTS ., Entered in computer: Yes PUBLIC HEALTH DIVISION -.TOWN OF BARNSTABLE., MASSACHUSETTS. 1 2pprication f�o�r 30ig�paal *pgtem Congtruction Permit Application for a Permit to Construct(�)Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components � / � 0 Location A 2I r Lo � Q - /(?, Owner's Name,Address and Tel.No. ,�, Assessor's Map/Parcel fap � �y 0�p{ y a8, Installer's Name,Address,and Tel.No. f[ De igner's Name,A dress and Tel.No. B- 95F3' -a o 9T Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( '.,� Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 6 gallons. Plan Date 8 ; Number of sheet evis*on Date Title 7# 14). GS Size of Septic Tank ' d Type of S.A.S. Description of Soil f �k, Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: h 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 B f Health. Signed Date Application Approved by Date_ y Application Disapproved for the following reasons e: Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(k.)Repaired ( ) Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 3 dated s —2— 9 2 Installer Designer The issuance of this pe t shall not be construed as a guarantee that the system will function as designed. Date Inspector No. 9 a— (��'�� -------------------Fee �Q THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwigpogar *pgtem Congtruction Permit Permission is hereby granted to Construct(1C)Repair( )Upgrade( )Abandon( ) System located at and as described in the above t pplication for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local-provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by t PLOT PLAN Corey LOCUS MAP a,7,, �E ,;Str f N_ Z 0 F r_ Job Number D.93-I Pepe I Cf 2 ri a 5c ALE R. z N 7/31/97 West Barnstable Road, Barnstable, MA T °S /I LOT NO. ME ' ; LO, PARCEL 4`.ooz s' DEEP OBSERVATION HOLE# 1 LOG IJ N ^n LOT APEA 1.•iO Ac- t_ _ _ _ Performed By: Jeffrey S. Colby Witnessed By: Jerry a- BOIi So l U - - - ev.. Depo from $a Shc Te+dn 6d Caw loll Aloov 00W fSUVO N.Eton" o T 1 A R f A G F LIE 1A 1 t. ` Fbrlten (U" baAdMf.arriEEe ney, `lwl Inc sa ' I 53.8 0 - 10 A Loamy Sand 10 YR 4/4 None ~� 53.0 10 - 24 B Loamy Sand 10 YR 5/6 None 51.8 24 - 120 C Med. Sand 10 YR 6/6 None I r cove / R'v I f Glacial Outvash L. Parent material(geologic) \' ~� 1 Depth to bedrock Depth to Groundvoter "Z S ` Weeping from pit face No Standing voter in hole No Estimated seasonal high gramdvvater - t SCALE ' lIN, = 2083 T-r vA� :: EL AL ooL LOT 4L .00 1 3F GENERAL NOTES ELEVATIONS REFER TO APPR0X1AAATE /J.r, V. L. SEE B.AA So. LoT c3R4JfR ALL CONSTRUGrION AND MATE,31AL S TO CONFO,QM TO T/TLE 5 OF THE 0 MASS STATE ENv/R0Q.NEMT4L CODE AA/D THE &OA,RO OF HEALTH RE0UI,1PEMENr5 FOR THE TOWN OF $gRA.STR �LE Aq 1 3 ANY CHANGES TO NI S PLAN MUST BE APPROVE,? BY THE BCW RD OF HEALTH AND SCA40FIELD &ROTNERS, IAIC. 0 4. NO PERMANENT STRUCTURES SHALL BE COA/S1-RUCTED OVER THE Corey l00� EXPANSION AREA Job Number 0--9332 Pete _2 of 2 5• POR PPOPER PERFORMANCE, THE SEPTIC TANK SHOULD eE INSPECT,D � 7/31/97 West Barnstable Road, Barnstable, KA AT LEAST ONCE A YEAR, IT SHOULD BE PUMPED WHEN 77fE TOTAL s3 a JR 53. DEEP OBSERVATION HOLE# 2 LOG DEPTH OF SCUM AND SOLIDS ExcEEDs /3 OF ITS LIQQlo DEPTH. Performed By: Jeffrey S. Colby Witnessed By: Jerry-Dent'r, BOH (;, ALL TOPSOIL , SUBSOIL OR ANY DELETERIOUS MATERIAL MUST BE / bepthfrom Golf GelTtNure $dlCelor 6WMORWp Other(druetare,stones, EXCAVATED AND REMOVED TO A 0/STANCE Of FEET FROM Elev. flat>an ( � baAdws,oanstency. ALL SIDES OF THE LEACHING AREA. BACKx/LL AS RE-OU/QED W/TN int sa K CLEAN GRAVEL OP SAND A4ATER/AL A44V/NG A PERC. RATE OP 53.8 0 - 10 ♦ .oamy Sand 10 N 4/4 None 2 MINUTES PER IA/CH OR FASTER. t 53.0 0 - 24 B oamy Sand 10 YR 5/6 None 7 5CHOFIELD BROTHEQS, INC. DOES NOT ASSUME 2ESAONS/B/L/TT } 51.8 4 - 120 C ed. Sand 10 YR 6/6 None FOR !NA7EP/ALS THAT /NAY BE ENCCtJNTERED DUQ/N(, 1 n) EXCAVATION. 8. INSTALLATION CONTRACTOR SHALL CONTACT SCHOFIELD BROTHERS PRIOR TO BACK, FILLING FOR SYSTEM CERTIFICATION. LOT I o 45- Z 2. C�Qo o c Glacial teas - I 9.NO KNOWN WELLS EXIST WITHIN 200' OF PROPOSED LEACH TRENCH, Parent matuial(peoiogl ) Depth to bedrock Depth to Groundwater Z S� Weeping from pit(aM No o , 1 / Standing voter In hole No Estimated seasonal high groundwater 0 S s Perc. Test: inv. is 45" e�L C1k%A./&W.-,W-Erw d►u 24 gal. in 15:00 min. r-+- C S 2• 3 7.'a PROPJSrE D TOUR L/N6 b S•* Z - ' << Q� ll--1) __ - Ex/STING COti '.'UR 1 O �Sr � EX/STING CE aPooL 1 00 _, f - --W WATER LINE P R o a n S E D DESIGN DATA I. 6 STIMATED HYDsRAL UC LOAPMAG PROPOSED ! ' SALION SEPTIC 7A,,r: r,4 4LF-AL 540ROOM9 AT /AD GALLONS PE,e DAY re,! SEDROOM w 330 G.P D. ( PROPOSED D/STRIBUTbN BOX I GA ,&AGE DISPOSAL IS -JOT ALLOWED W/rjW MIS DES/G,1. 2. 55EIT/C TANK SIZE PROPOSED LEACH !;(_/l/C N AVERA6- DA/LY Fww .. ,3 3 o X Z D e-' % a G G o GALLONS (MI Ar/MUM) SEPTC ANK PROVIDED GALLONSESE VE A2EAPROPOSED LEACH B, JES/GN pERCOLATA7A/ RA72r < S M P I. (GLASS Z� L* , *5IDEWALL LOADING GALLONy/S.P k'.X' EXISTING SFrJT ELEVATIONS BOTTOM LOADING p. -2-4 GALLOAZI.S.F ! ro 4. LEACHING AREA & TEST HOLE LOCATION 1 AV C. 71 M 91O WALL ARZA PROVIDED . 3 7- 5.o F x rn. 74 , F.1./S. PROPERTY L ,JE �L'a J �L�C Z i C'4oi u Z 34 • 8 GAL, / I TOTAL BOT7DM AREA PROVIDED - 3 Z V S F. X D. 7-4 GAL.IS.n B.P . S3, G v PROPOSED SPOT ELEVATION _L 3` g TOP Of �,. g �-� ELEV 55•o t - _ _ GAL. 1 7` 01 , - UG P Ro POSf UN 7 G R /J T r L) r/E g INAx/AVA4 ALLOWABLE LOAD/NC, (WADER TITLE 5) 4 7.3 C. GALLONS f i ACTU4L HYDRAULIC LOADING = 3�O GALLONS (SEE /Q) P �oT AS - Z Si MINIMUM SIZE LEACHING AREA EXCEEDS T)4A7 ALLOWED (JA/Me c a . aorm THE TOWN OF RFC "IsTACLE BOARD OF HEALTH zzgleeAfEN75 _-- _-- --- ^-_ I ANO T/TLE .5. PROFILE Of SYSTEM _ TYPICAL LEACH ?'RENCFl CROSS - SECTION - -NO SUALE -- I - NO SCA l_E - tMANHOLE 4 COvER - MIN. DIA - fa" Z TRrkj1� s•T_ S gROUGNT UP TO W/TH/N (o" Of FINISHED 6RAbE + _ P/N/SHED GE'ADE 5'a 2 - �� 7- PROPOSE SEWAGE DISPOSAL SYSTEM -._•� 17N 51 s_ - --i I " LATER of -- -- \ F0W PQoP& SE D TwR R � ~ EE Q F_DO o o A.n DW f LL r �•!G. -- v .5 !_ _ /4? kfIAIIMUM Hr 044 OSTERVILLE W• BAR.ISTApLE Rb j `• FP, STONE - --- -� OS ERVrLLE. MA J / - F LOW UUE - - ;NL�r- _/o" niv - S 3, � - ,`Sr. 3o IrI 4"DA4. T/�:H.T ✓U/NT P/PE---� v!✓. . Z 3 � APPLICANT TEL. NO. �;/ i OF /¢"-l� WASHED S;ONE \ e5's�o E�� - -N✓. Z. 1� ` �f RF'ORA7FrJ .ti TfEV�N1 "lb 00AIALD :OPtF-Y `Sod1 4t13 -Lo91 QJ �\ PRovrOE Gas gAcfcE 1. - ---- ZG -- -Z - NK �`/. $O '. { II j COREy LA,lE - SANITAQY" TEt InI.(F)ir--� ��+ - Z O +-;• D/STRI80T/C1111 Box CI.F_v S I. SO ---- 4o .l-- - - Mr"ToA MA O2tBL -- ------- ------- _ � _ _-. - _ �, DATE SCALE • Aa r►Ofed " - DurLaTS --- _ -_ 0.5 of N,4 ��,:.q u•T�77'2-.'T's* r-:'.y ..! INvEer ELEV47/ON5 ,f i:LL +I -._.__- .. ,..� •!�t %- 7 L- 'A l� SPrtC TY1NA< OUTL:'r'8 -/f Tn P.F TI _.n,•rF i � •. �� ✓ S7o�.E �APAGIT _ Soo GAC:ONS I OUT(-F AF Pueje, ) i-- 50TTOrt1 OF m5 To 1 .._ ESK,NEDbY: QQAWNBT CNEGK Sr FOR FUTUQF_ EXPANSd()lJ -tjQ2PO.cES Z E L EV = S O ''U % S✓f S v'E 12 M P PRECAST RE/NFORCFD CCNC,C'FTF :- `� T�/,`I,- ,'SEE PLOT P(AW FOP WCATIO/�•', - _ -� �` w ;•L-r_ ',,> St_C7/UN Is__ SCHOF/ELD 8l?OTNEIPS t7i f1f•E. rJIJ'(:. NOTE ALL P/PE TO Bf 4.� PvG -IGHT ✓DINT OUTLET PIPES SHAI (,,L L_fVF.l _ 4�- j t ENGINEERIN, SLAPVEr'lNG • PLANAIIAII�i FOR A' LF SST ;wrI rEcT Z-TR(.titC UE_S RE Q P,O BOX )Ol, /Gi, CRANAERRY N/6rr•v.4Y, ACLEAUS, M4 4. 7