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HomeMy WebLinkAbout0169 OYSTER WAY - Health 109 Oyster Way Ost.0ville .; A 071,--01 l .003 t, 7 A Commonwealth of Massachusetts Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments T M �M 169 Oyster Way 4- Property Address # Patricia & Harvey Sher On Owner Owner's Name / information is required for every Osterville V Ma 02655 4/4/18 page. Cityrrown State Zip Code Date of Inspection sl 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 r oZ Qa on the computer, i use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain 4:1 Company Name 35 Content Ln Company Address Cotuit MA 02635 Cityrrown State Zip Code 508-364-9587 SI 13522 Telephone Number License Number B. Certification 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 Evaluation by the Local Approving Authority �. 4/4/18 In ector's Signature i Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 ,Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 5- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 169 Oyster Way Property Address Patricia & Harvey Sher Owner Owner's Name information is required for every Osterville Ma 02655 4/4/18 page. CityrFown 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: System contains a 1500 gallon septic tank. As well as a concrete distribution box and 5 500 GI Chambers 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): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 169 Oyster Way Property Address Patricia & Harvey Sher Owner Owner's Name information is required for every Osterville Ma 02655 4/4/18 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): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 169 Oyster Way Property Address Patricia & Harvey Sher Owner Owner's Name information is required for every Osterville Ma 02655 4/4/18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 169 Oyster Way Property Address Patricia & Harvey Sher Owner Owner's Name information is required for every Osterville Ma 02655 4/4/18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins•3/13 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 ,•'y 169 Oyster Way Property Address Patricia & Harvey Sher Owner Owner's Name information is required for every Osterville Ma 02655 4/4/18 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage backup? ® ❑ 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): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 169 Oyster Way Property Address Patricia & Harvey Sher Owner Owner's Name information is required for every Osterville Ma 02655 4/4/18 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage 198 GPD 9 ( Y 9 (gpd))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts (z Title 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 169 Oyster Way Property Address Patricia & Harvey Sher Owner Owner's Name information is required for every Osterville Ma 02655 4/4/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Not Provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 169 Oyster Way Property Address Patricia & Harvey Sher Owner Owner's Name information is required for every Osterville Ma 02655 4/4118 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2008 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 Gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 117 Commonwealth of Massachusetts ti. W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 169 Oyster Way Property Address Patricia & Harvey Sher Owner Owner's Name information is Osteryille Ma 02655 4/4/18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" 3" Scum thickness Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle it Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM , 169 Oyster Way Property Address Patricia & Harvey Sher Owner Owner's Name information is required for every Osteryille Ma 02655 4/4/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): `Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 169 Oyster Way Property Address Patricia & Harvey Sher Owner Owner's Name information is required for every Osterville Ma 02655 4/4/18 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 Level and at normal level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 169 Oyster Way Property Address Patricia & Harvey Sher Owner Owner's Name information is required for every Osterville Ma 02655 4/4/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): System is functioning as designed Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 169 Oyster Way Property Address Patricia & Harvey Sher Owner Owner's Name information is Osterville Ma 02655 4/4/18 required for every 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.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 169 Oyster Way Property Address Patricia & Harvey Sher Owner Owner's Name information is required for every Osterville Ma 02655 4/4/18 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts . Title -t e 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 169 Oyster Way Property Address Patricia & Harvey Sher Owner Owner's Name information is required for every Osterville Ma 02655 4/4/18 page. Cityfrown 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 +ft 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: 2/7/07 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: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r TOWN OF BARNSTABLE LOCATION if(o 41 () SEWAGE# 2t� - L� VI ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. Rk qo}y SEPTIC TANK CAPACITY !SOO LEACHING FACILITY.(type) so CA t�,yo\\•� 5, (size)14 NO.OF BEDROOMS —S OWNER' - \e a, 4 PERMPI'DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facllityj feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY r v $ 5 100 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 169 Oyster Way Property Address Patricia & Harvey Sher Owner Owner's Name information is required for every Osterville Ma 02655 4/4/18 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 117 of 17 ILA Ck/skr- u c)C oS+e,rv', l 1 I � f 1 f _ { i i r7�ocy�1T3i9Q w�-v�f C-¢� hCiiRi f . � Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 169 Oyster Way Property Address Ellen Valentgas Owner Owner's Name information is required for Osterville Ma. 02655 2/4/2011 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company.Name P.O.Box 763 Company Address Centerville Ma. 02632 Cityrrown State Zip Code (508)428-4028 S14454 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 Evaluation- the Local Approving Authority 2/4/2011 Ins ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a'i shared system-Uo�rl has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the.-,-, report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under M the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Di osal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M , 169 Oyster Way Property Address Ellen Valentgas Owner Owner's Name information is required for Osterville Ma. 02655 2/4/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with,a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 169 Oyster Way Property Address Ellen Valentgas Owner Owner's Name information is required for Osterville Ma. 02655 2/4/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 rt: Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 169 Oyster Way Property Address Ellen Valentgas Owner Owner's Name information is wired for required Osterville Ma. 02655 2/4/2011 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 F Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 169 Oyster Way Y Property Address Ellen Valentgas Owner Owner's Name information is required for Osterville Ma. 02655 2/4/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. 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. i t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 169 Oyster Way Property Address Ellen Valentgas Owner Owner's Name information is required for Osterville Ma. 02655 2/4/2011 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,•'y 169 Oyster Way Property Address Ellen Valentgas Owner Owner's Name information is required for Osterville Ma. 02655 2/4/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): NA Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2/4/2011 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 169 Oyster Way Property Address Ellen Valentgas Owner Owner's Name information is required for Osterville Ma. 02655 2/4/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form "s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 169 Oyster Way Property Address Ellen Valentgas Owner Owner's Name information is required for Osterville Ma. 02655 2/4/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3'feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: 2" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M ,•''y< 169 Oyster Way Property Address Ellen Valentgas Owner Owner's Name information is required for Osterville Ma. 02655 2/4/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" 0" Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 14" 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.): Pump tank every two years.lnlet and outlet tees are in place.no evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet 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 t5ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 169 Oyster Way Property Address Ellen Valentgas Owner Owner's Name information is required for Osterville Ma. 02655 2/4/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 169 Oyster Way Property Address Ellen Valentgas Owner Owner's Name information is required for Osterville Ma. 02655 2/4/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has two outlet Iaterals.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 L - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 169 Oyster Way Y Property Address Ellen Valentgas Owner Owner's Name information is required for Osterville Ma. 02655 2/4/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy dry soil.No signs.of hydraulic failure.Chambers were dry at time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 169 Oyster Way Property Address Ellen Valentgas Owner Owner's Name information is required for Osterville Ma. 02655 2/4/2011 every 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.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "r 169 Oyster Wa .. Y Y Property Address Ellen Valentgas Owner Owner's Name information is required for Osterville Ma. 02655 2/4/2011 every 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 cu.., 100 wL ZW- �`� Z'� • $3 I nf' 1/31/2011 10-17 AM Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M ,•''� 169 Oyster Way Property Address Ellen Valentgas Owner Owner's Name information is required for Osterville Ma. 02655 2/4/2011 every page. City/Town State Zip Code Date of Inspection D. System Information. (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LC 15' 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: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 169 Oyster Way Property Address Ellen Valentgas Owner Owner's Name information is required for Osterville - Ma. 02655 2/4/2011 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 II TOWN OF BARNSTABLE LOCATION SEWAGE#. 2c:d-4 ' (Y %— VILLAGE ���C'tc ��� �. ASSESSOR'S MAP&PARCEL 71 , INSTALLER'S NAME&PHONE NO. k GQ\O_ 0—+y SEPTIC TANK CAPACITY \N.—yZ LEACHING FACILITY:(type) (size) 1'Z"K NO.OF BEDROOMS S OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300 feet of leaching facility). feet FURNISHED BY i No.. , a .; r� " ti Fee l� 4 , I Entered in computer: THE COMMONWEALTH OF MASSACHUSEI�TSYes PUBLIC HEALTH DIVISION . TOWN OF BARNSTABLE, MASSACHUSETTS ZIPPhcatiou for Wgpogat *paem Construction Vlgmit Application for a Permit to Construct(,Repair O Upgrade O Abandon O Q Complete System ❑Individual Components Location Address or Lot No. Q�9sr—r wner's Name,Address,and Tel.No. tf 6s�n►\4e ►�ht ��nne R, rns�ph Assessor'sMap/Parcel d _Q Of3� 12 , " bZ Installer's Name,Address,and Tel.No. �� V� esigner's Name,address and Tel.No. ' ( 4;7 S-4 %B-334 Type of Building: Dwelling No.of Bedrooms s Lot Size A} It 5q-ff. Garbage Grinder (0) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 5SS7 gpd Design flow provided �j( � gpd Plan Date fv 00 Number of sheets Revision Date Title s � R_dp -�wYQct3�ert^�Q��� Size of Septic Tank Ii9d0 611 Type of S.A.S. S"S00 (vr`, Nmben, to Description of Soil 10,(o'SZ_ O-G" O Lb�99, (0 ?., t- "Z- I®YR j�Z iyio..50b Lj!,, rOmr oQ�RpoCS IL 2Z c� 22-Q 0 Z, Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned a es to ens a construc on an maintenance of the afore described on-site sewage disposal system in accordance with the prov ' s e 5 of the Env' onme tal Code and not to place the system in operation until a Certificate of Compliance has been th' Board Signed Z Date ,, — Application Approved by Datel Application Disapproved by: Date for the following reasons Permit No.�� �"2 Date Issued 6 7 7 No. . 4 J .. �` .�. �t, ,� Fee J i F"-'' . i�. {'! All . ,# FF Entered in computer: THE COMMONWEALTH OF MASSACHUSEI As PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE, MA5SACHUSETTS Yes application for �Bitponl 4�P!Aen,,Cow truction emit Applicationkfor a Permit to Construct �Repair( ) Upgrade( ) Abandon ) E! Complete System ❑Individual`Components I(o`I Ogsrr l�Y `' Location Address or Lot No. -ti' Owner's Name,Address,and Tel.No. vsXc'cv\�; i/llfr�r A wime. R,9'rrl/�ph`yy_ y, l W,�Qt� 'Q�Y1 Dc�� Assessor's Map/Parcel d-7/ —Olt_oo s l a. .,, c4 Vale ,mA- OZ(01 Installer's Name,Address,and Tel.No. y { esigner's Name,Address and Tel.No. G'(Ji✓ '/1`ti� . �� �� �Slt e�"¢t�xd a,o co. c S9 f�_ �7_(aSS GOO- 'g-34 I Type of Building: l Dwelling No.of Bedrooms s Lot Size IkCtQfl Garbage Grinder (Nd) r Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �jSS gpd Design flow provided gpd Plan Dale rCY OCQ 5 ZOO-7 Number of sheets Revision Date Title S� Wey\ Size of Septic Tank 119M 61 Type of S.A.S. S`S0� �k1, Qhrkmjk's irb 0. 1 lx q& q f Description of Soil . -ta,(03Z n—[o (� Lt� al (kl A, Leger I l,yk s/z_ VYIF=J tjPaML�)sZ�Rvtcs ZZ- MO. 5�,n Nature of Repairs or Alterations(Answer when applicable) � 1 s Date last inspected: ` 9 Agreement:^^ ., The undersigned agrees to ensure the construe on and////maintenance of the afore described on-site sewage disposal system in accordance with the provisions of�T lI e 5 of the Env ronmehrtal Code and not to place the system in operation until a Certificate of Compliance has been<is�d b jthjsBoard ofHealt�. Signed _ C / Date Application Approved by Date �/7 Application Disapproved by: Date for the following reasons Permit No. f'T: � �'�7 S Date Issued 0 7/7 -- _ . _ _. __ ________________ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS V" Certificate of Compliance THIS IS TO CERT F hat j the On-site .ewage Disposal Tstem Constructed (� Repaired ( ) Upgraded ( ) Abandoned( )by / I t /S at 1ki a 4T- has been constructed in accordance �� with the provisions of/Title 5/a�nd the for Di osaJl/S�ste/mfCo truction Permit No. dated Installer /t Q /'1/ ( l)Wal �(��!/� Designer SV I u% ►'� #bedrooms l Approved design flow e7�� gpd the issuance of this e J,rt shallot be const'r ed.as a uarantee that the s stem w�function as d/esi ned� G r Date p 2 U1 / /) g Inspector ————————————————————————————— - -- -- --- 50 No. � Fee : THE COTNIMON v' ELALT H OF ivIASSACHUSE T TS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS =itpoal �&pgtem Construction Permit Permission is hereby granted to Construct (1-1 Repair ( ` ) Upgrade ( ) Abandon ( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special condQby ' . Provided: Construction)must)e completed within three years of the dates pe it. Date / 77 Approved s t 5'High knee wellf Linen apt. closet Bath - New Bedroom +' \, 1.1 • / 13'-6"x 15._6o s A. O ,'FAMIILYROO� _ 202 W SUP r' c r. IpPreliminary* Sketch 4.7 1' SECOND FLOOR PLAN NM � aluF:aita=ra 1 (l � � Proposed New addition °�"°ow�°" 2nd floor bedroom and bath a 169 Oyster Way OsterviII6, MA coa ❑ _ lAeu EmWgs are lnsbummbolM 4Meb sxryr�iestm Vis pojM hgmm NNAcvrebbn a reseNee n�K uxLary xmisx: am.fmm.re�paamm�xw ? �J D f ozws.ayam AMAttb 03 s 0 ] w FAMILY ROOIA U 2. L E DECK i C e'STEP DO ❑ P DECK EeorsooM - SECOND FLOOR PLAN P03 / GREAT ROOM 504E:]116=TO' . arEn ro BELOM I xagtx , Wore,sEE D*L PLODR runs nz sERIEs - . c i 'LINEN f "TH - - •N cL "� N EL a3 YDE p8 i DEL cu � I' uluEn a > EATx ] ® BE 20oO Sh-nue: SECOND FLOOR PLAN SECTION 15 CUT 0 h As Noted .� IN P.os. RI+JM DEC EM 0606 I CONSTRUCTION SET NOIFFYDEIIIIEk IFsioluu' —O TMEN A 1 .2 DTIDN FROM DRnw 1 i DECK I cwsET 6 'I � Thme maryl are lnSWmmbol L_______ - seebnevrl.mm Gil M.kv mxb realm - MUOROOM - � - aO menM fig.pNb R&MB mR'4fw � entl e9���ykAoul LAUNDRY R MA BATH ® � BED OOM ® 6tW5,LpRmArtbxb ' S E 4.9 ® �.. BKITCNEN O O O O®® DECK afi$ CL r-- O DINING a 1 � I I I ENTRY ENTRY I. DECK I ® I 1 I I I i I I 1 G E®ooM FIRST FLOOR PLAN O i I R.R. - 1 I I W I rolE:sEE oR FLOOrt vinrvs wa 5ER roiES nND O11 HSioNS I O 3 N a�9 I e i� m r---__ BATHROOM BE C RATIO y Bhm:l TIBe: ----i FIRST FLOOR / GARAGE -- - PLAN I ® UE9 __ _ I I B DROM e. As Noted 1 I - RI+JM --------i O led m 0606 CONSTRUCTION SET BEN A 1 .1 III - :-r^018 09:19A FROM:R&H CONSTRUCTION 5085409074 TO:15087906304 P.2 s ,.101013/21106 89.22 5084283115 SULLIVAN ENG INC PAGE 01 Town of Barnstablc 0. FA, ' Regulatory Services ems,} Thomas F. 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J AP - Aquifer Protection DistrictQ • f ' Oyster Way Trustg�H W. Carmen Elio, Tr. cHLDH n o Fnd N88.15'S8"E 290.41 50.40' Location Map N E E N w A 78.8 f S ZONE: POD I 5 Area (min.) 87,120 SF 6 5' ------- (� ;--------- Proposed ( ) 1' 1 Fronta e 2 0 0 0 0 0 N..... cn 3 Width g(min) €125'0 Garage y Setbacks: -:.:.....::-.............. �-------- -- �' �c Front 30' .... ... Existing Septic Side 15' Z System r------- r rn Rear 15 0 0 I m Qz N) r m Paved FLOOD ZONE: Drive jCDZone C s` S 1 =• G I µ� s Community Panel No. a i ; #250001 0018 D y _ July 2, 1992 0 w o w o � �w o _ a fl o I� C�FB H P TANK S88'15'58"W 290.41' LC8 Fnd Fnd O n N/F James F. Langway NSF . John D. Osmond Ill & Henry L. Osmond,Jr , Y►�a Of s s L t c RICHARD R. L'HEUREUX p NO. 34312 0 o4�iP3,9�QISTE��O ,tea • AN Sheet # Title: Prepared For: Notes/Revisions: Plan Showing Proposed Garage. CapeSury 1» � y 1.) The property line information shown was Scale: =40 Harvey & Patricia Sher 2742 Beauelere Rd compiled from available record information. 1 OF 1 169 Oyster Way East 7 Porker Road °ate: Jacksonville FL 32257 2.) The structures shown were located by an Barnstable (oyster Harbors) Mass 0sterville MA 02655 311OCT112 on the ground survey performed on (508)420-3994 (508)420-3995 fax or between 161NOV104 & 14/MAR/11. copesurv@copecod.net �W9 C372_5g1 � 2 I 4.4 4.4 22'$' 1'-W b'-B' 24'-10• 0 � 3 o DECK r CLOSET I I ® These drawings are Inswme.nts of c i, i ------- SeMm for use soleywlth respect to M project.0grdm Arddleds retains 1 __ a0 reserved rights lndu(H g copyrights MUDROOM iv aW%,A notallmvrepmdudkmvMoN NOOK MRexpressvdtenconsed LAUNDRY O MASTER MA BATH - m ® UN BEDROOM i� 'D 02005,Ingram A¢Nfeds SUITE t 1 A ® 43 11 49 ❑ tv 2 �• ^ 4� KITCHEN L S O O O DECK - r✓ m 2 �� O B a m ® cc—— A r 50'-10 14' a— J / CD CL ROOM ° 2 // 02 IL -ll 4 e•w core:m.w.m / w ww oaumm+ / WAa"/ EIonL DfTma. ENTRY ENTRY I I - +n+mv a�+n sw unman DECK " I I I I 2 4.1 i i I GR'EATROOM FIRST FLOOR PLAN I 1U - SCALE:011G=1'd O I I I I I NORTH NOTE:SEE DTL FLOOR PLANS A2 5ERIE-9 FOR NOTES AND DIFIEN510N5 I I I e I V I I � I I I 2 I .�ewe1° (u o as ® i , . _0) �.---- BATHROOM C ---- l cu m 0 ----� _J 42 PATIO , C Sheet Title: rnFIRST FLOOR GARAGE ------ n a PLAN ff076 GUEST. 42 I BEDROOM -- — (/ � G�� /7 Scale: AS Noted09 -----____—� Drawn By: RI +JM --------- --------L----_---- 1 Project No: 4.I 0011 0606 20' 50'-4• CONSTRUCTION SET ISSUED O 7 q 1 . 1 IS THE RESPONSIBILITYLITY G.C. OF THE 70 NO R TIFY DESIGNER OF FOUND ERRORS OR WHEN CONSTRUCTION MAY DEVIATE FROM DRAWINGS z I 4.4 4.4 2I'-0" 3 4.4 O _ ereselaruspareln respesof Service for use coley vd0 respect to Ihkpr*cL hgremArchllectsretahs A - - all reserved rights hldud'ugcopyrights aW wM not allow reproduction vAOmut express written conserIL 5 HJ B @2005,Impam Architects - 49 i F O FAMILY R00�1 V a3 I ik Ri to e 8 r \ I t t I ♦ \ i ca I I El / \ i WETBAR i I H•STEPi CL DN IF / — i 4 © © ❑ i� 4.2 issn om�m.�onr i i Nu omo osapm, oazrm cmaae nct`uc i aoza.or nmmou°ros'"�ao i Q DEC O +o.rom onosm uooa I 41 BEDROOM i SECOND FLOOR PLAN 203 GREAT ROOM �. 'SCALE.3116'=V41' .. OPEN TO BELOW I NORTH • i NOTE:SEE DTL FLOOR PLAN5 A7 SERIE5 Al LINEN I V '4 BATH C 205 I u, Q -N e J gg ^2 'l CL I OPEN TO Cu 4.2 206 I BELOW - 1 Z3 LINEN - •V � 5 'V 0 Q 4-2 BY09 BEDROOM Sheet Title: 207 O� SECOND FLOOR PLAN O - Scale: n 1 SECTION IS GUT As Noted m 42 ON FA.S. Drawn By: RI +JM DEC _ Project No: I 0606 1 CONSTRUCTION SET /w` 4J - ISSUED 0 O /.� 1 .2 IF IS THE RESDESIGNER FFOND ERRORF THE G.C.TO NOTIFY DESIGNER OF FOUND ERRORS OR WHEN CONSTRUCTION MAY DEVIATE FROM DRAWINGS '"�.. NOTE. •• w AND CONTRACTOR NEW PLUMBING VERIFY THRU bt PLR.CLOSET BELOW 4A. REINFORCE ANY JOISTS AS3 NEEDED PENETRATED BY ANY WASTE OR WATER LINE PLUMBING S 10'-TYz' S Ib'-b' I p « PROPOSED _ Q'WALL BATHiiiiiaiiiiiiiii i CTR w/RIDGE bz OPTIONAL I 2-1668 .,iiiii.,,•,.,.. ....,•..i iiiiiiiii% 4! I CLOSET 46" I I I BUILD OUT STEP II �� FOR PLUMS.CHASE ..•,.4065 „•.•..,,- I PROPOSED I 3 p REMOVE EXIST i \ DOOR E WALL — I S-b HAS ALLEEDED FOR i I I -CLG IS' z�Q z Y�f�Gy�SgUrz g i DH3224 3: w �wffi>i� I \ I EQUAL NOTE, IL €p�,5 Q�s� • IT.. w/RIDGE CONTRACTOR TO INVESTIGATE THE BEARING O o,u�� HUM. I y_i CAPACITY OF IXISTiN..FLOOR AND SUPPORT U zrc I - CARRIED TO BASEMENT, TO BE REINFORCED TO SM LIVE LOAD. I \ w « I \\ A.3 Q w I Cs $ 8cn SECOND FLOOD PLAN w U Z W NOTE, '^ Z CONTRACTOR TO VERIFY (n p AND ROUTE NEW PLUMBING - - Z I-w}-d THRU It PLR.CLOSET q A3 J Q E OL < gue Q OJ a Lu LL J Q 1 L O FRAME IN PLUMB.CHASE- ALL ALL WINDOWS ARE TO BE MARVIN WINDOWS j= WALL KEY R���Fpg as O EXISTING WALLSd �� Q WALLS TO BE RE1OVEDd� 3e8 EMEM—/2/. PROPOSED WALLS m 1. ALL EXTERIOR WALLS SHALL HE 47(6 •f O.C.UNLESS OTHERWISE NOTED. O 2.A}L INTERIOR WALLS SHALL BE 2X4 I N •Ib O.C.UNLESS OTHERWISE NOTED. m 9.CONTRACTOR SHALL VERIFY ALL WINDOW - Cf ROUGH OPENINGS PRIOR TO ORDERING WINDOWS. A ,.� Z 4.CONTRACTOR SHALL VERIFY ALL DIMENSIONS lV �— PRIOR TO CONSTRUCTION. CONTRACTOR ASSUMES DIMPENBIONS FOR �o"°OR FIRST FLOOR PLAN D '" THE ATTENTION OF THE DESIGNER. Ta C Q 4 '• - a , it ASSESSORS REF» , r ,� �!\• - < <� . ftgp T4.P+orcef ff 3 � .�s.. . .,- .•=t ,o. OVERL4YDISTR/CT: - - Locadon Map • -zoaof• O la*? SFo WdWOO p O _ , j,-:ate`= & wb� ._ � -� tit � Now W _ FLOOD ZQA Peom'ma ST R L .Pats : • - . r t\\1.1 �NZ r1a\Ue_z C•�-. h� tztlS T lt`\S�Y1LL�t�. - ,• Q D1�►\.- nip\l�i.(� \..\1L.1.._. �\� '�\�`� V�Ll_ l'N S�ic_T l C1N�v-- C� M LT n r�Hn s1 [..VAT") Prepared For. Notes/Revteionx Sheet Title �' f / 1.� flMe property line inlarrrto cY snfo ro do u` v Scope: 1'=40' Honroy � PetrtcTo Sher �„paea hrnt owQoare .ocor'd �rQrmar,on- SNc Cap 2742 Bea+udem Rd -� +"! . r1r 1.11i, F` c d :�•ite: r. .�acksonvRfR F1 32257 2.) The srrucfure,v shown 1—CO located by on _ t i PERC TEST: 10,632 TAREJ pml�2 PERFORMED BY:PETER SULLIVAN,PE-SULLIVAN ENGINEERING ZONE. } ea'a' WITNESSED BY:DAVID STANTON,R.S.-TOWN OF BARNSTABLE , + - a 1ANUARY 1%UMMUMMOMM ,2ooa RF-1 (RPOD} Bxua Pleb P,ovlded For sa Nau4 oyp.) � R Area (min. 87,120 SF zf f°1 TEST HOLE-I TEST HOLE-2 Fron to (Mtn) 20' t ' Possible Fugue 1000 Galloe ...�.� peer tee Mayp e,,, EL.23.8 EL 23.8 Width min) 125aok Ae eew Bel Far Sewed ICIteLeu �''� OLAYER O LAYER cs: r nm.sroe. PARTLY DECOMPOS® PARTLY DECOMPOSED r •• , LEAVES A TWIGS LEAVES 1R T[VK1S q Front 3D' ISOooanoe aaem.xlao LeAtsIl+r1 s�" 0e AtAY13tI0YR3!! w YER Side 15' •', >2 Septic Tank D-Hooc cxAee>im4 ORAYLSNBROWN . M®.swNO a�cu�lCs Rear 15 � o ••se l�, p.� � Plow BLrue MID.SAND W/SOMEOR(IANIC3 228 14 22b As rw B LAYER 10YR416 BIAYER.10YR416 Ober DARKYELLOWISHBROWN DARKYELLOWISHBROWN a FLOOD ZONE: 4�•na• MED. ND WI SOME FINES 22.0 MED.SAND W/9GME FM 21A ,a Beddio&-rx,ee8efllb Irmmmrie/RarerellR�m CL.AY1Rt25Y66 LAYER _5Y& Zone C se Per Thk S ,z OLIVE YELLOW OLIVE YEL OW IiI r u m (Sec Notes8&9) 7beOrapaie*rvirw�idthSa STIONOFCHAMBER MED.SAND 1 MED. Community Pane! No. CRO SSEC �;* y Ieeae.•alb _ xi,s•.a '`< 2y . NOT TO SCALE 30" PERC TEsr 213 MOOR wATERENODUNTBRBD- 250001 001E D 2s GALLONS IN I2 MIN.4s�C July 2, 1992 0' DEVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM :, 1 <2M1NA N 13.8 t1i am®dmaa NOOROUNDWATERENODUNTEM NOTT09CALE paroaonmaw,arlap Location IY/aA DESIGN DATA 1"_-z000i' SkgleF;&n*-SB&w= ASSESSORS REF.: Wim NO Oubego G=Wer DWVF1cw-Il0x3-550OPD Map 71, Parcel 11-3 Septic Tok S30 OPD x 200%-I1000PD Use 15000don Septic Taot OVERLAY DISTRICT. It55 Canc APron f LEACHING AREA AP - Aquifer Protection District \ -1 oyster w y 155 Trust H� swaPD/oa4-743 sFRe**W As Shown on Plan Entitled Z't f �- Joseph H Matzkln, Tr "Revised Groundwater Protection 4 Deed Book 9277/171 James K d Kathleen L Mingle SWews8-2(I2'+46V-232SF ctf 160263 Bo0=Ana-(I21x40-552SF Overlay Districts" - April, 1993 sptrwe CB H C8 H 784 SF Tow Proide vd M Fnd Fnd 50.40'240:01 LEACHIlVG CHAMBER DESIGN . / `. All Pipes b be Schedule 40.Use 5-3W OaL Lead,iog CLsmbeas in -O N88 5' 8"E 290.41 Lot 222 C 17 x 46 Wasbed stone Fidds as Shown. 21.49' (LCC 15354-131) \ \ n \ r � __ _--- 43,561-+SF \ p E \ I SEPTIC NOTES 2s 20'Setback (see Doc #954.316) _,_� I trti - 1 I 1 1 [Aeation ofUtalitiesShown on TbisPlm AreApprox.wt Lead 72 Howe -'--'--'-- a t� loAay otdvM=Fo Thaw ConhackrsbaR - -••-- --- ----- � i N 1� � (1-888.344- )• I 2.Tim Conuacbr is RequuW b Seem App apride Permits From Town 1 ` RES�R VE V��ED_ PROPOSE w y~ r ION i � I 3.The Wdw Lin con*uded m oeaedioaaon Vrdh OP D ( -_ , --� '\ \ I 1 COMM Wale,and shag be in Aacorsaooa With 248 CM R I.00-zoo 1 GARAGE W �.,� ! &310 OW 15.00.The wooer Line Shall be sleeved Wbese Requires. MI . / TRELLIS r.•'' R�-!' f �`'\ � � : I ; }� 4.install Rieea b Within 6"ofFkidW Onde(S PAuh d). I 1 BEDROOM •. / % �' S.An suucemes Buried Three Fed or More or ftod e, gyp•,, .� 10 ABOVE , 1 25 ie vehiownTraBin to tie H-20 Load'mg.u is the Eogkeds Reoommm&WnmdR-20AhvaysbeUaes. r 10 I 6.Septic System le to t odW in A000edmce With 3l0 CMR 15.00 dt \ + MIN. . 1 �. -• I 248 Clot I.00-zoo Laced Revision and me Town of B=*ble I. 7 92 _' ,. . zr#,� " PROPOSED " i -_�. Dowd ofxeelthRegnlatiom b li``• PORCH 4 -� -1_ ____-_ T.All Piping to be SO.4o Pvc. \` I S.Idet Tees Shall Exknd aMb mnm of 10" PROPOSED O �� PROPOSED I Below flee Flew Lace. SAS 10 Qj a NOUTS (TYP.) \ / j I 9.AnOulld Tee Shall ftftd14"BebwGwFbwLke. I PROPOSED 1 R UIRED FOR I 1 S > 22' PROPS�SS D-BOX i I �` 4 BEDROQM""• PROPOSED i I ` , DWELUNG �:. .w -. w' I L Legend•" z �.� SEP77C i PROPOS O v (AS BU,IL.T� ,.-.. - o '' ., �aa . ,,TANK p GRAVEL Q' .--""Z x8. -''' i a Deciduous Tree DRIVEWAY Q. c ••-..,„, .. .___„„,.�••".-.. -.-. ','` ._....•--•"" Foote,,.. •'" � I ° 1 ' - . -~" _ Coniferous Tree •, -- _ PROPOSED I o v '; I �,� / `'•-__---~"'"MAX. POOL ' i Sign 106 0 "'i / W r-- i� # Light Post m W P`w4"�, ,i;r 0 Water Gate (round) 1 I ►-3 TH-2iw © Gas Gate (round) V ' `T'.rR 49� Hydrant a'AE 0 CB/DH - Concrete Bound h on ' TH-1 �! N ` Z,► E7o. 2JI3 Guy N -•--•--•- � � Utility Pole / 1 --•--•--•--•--•--•--•-•-•--•-- aa I r •--•--•--•- •--•--•--•--•--•--.__.__.__.__•--•--•--•- - •- --•--•-�• - - �- " Alt�� � � Test Pit L._.-_ — / El=2i.96' (NGVD 29) /� i zat►w Overhead Wires Top f LCB Fnd o NK 20 77 r lJ 6 ` LP TA a+ \ j/1 � Zk 290.41' ` -" Update Plan to Reflect As-Built S88'15'58"W ,- — LCB � ' r _ _ Utilities, As-Built Foundation, 234.08' Fnd As-Built Dwelling Inverts, and — / NIF ee/DH Edge of Pavement ZkA (� Jomea F d•Dehdre A LMg1YRy Updated Proposed Porch, Driveway, Fnd ,n p�Osyl,a„d i ctf 162195 And Sewer Line La uts DATE: 06117108 tt , Bit Orive ctf 67606 e',r �°'°�° / REVISION: MODIFIED FOOTPRINTS DATE: 05 04107 TITLE: jt� Plan PREPARED BY PREPARED FOR. NOBS: S/ Q 1.) The property line information shown was Proposed Improvements Sullivan Engineering, Inc. Cape'Sury compiled from available record information. p p Ellen Val en tgas 2.) The topographic information was obtained At PO Box 659 7 Parker Road from an on the ground survey performed on Oste rt rville, MA 02655 Osterville MA 02655 P.O. BOX 1026 November 16, 2004. �6 pyster Way (508)428-3344 (508)428-3115 fax (508)420-3994 (508)420-3995 fox Ostervllle, MA 02655 J.) The datum used is NGVD '29, a fixed mean9 -� sea level datum. Barnstable ( ) Mass. Draft: JOD Field: WHKRL 0 ter Horbors R 20 p 10 20 40 80 4.) The intent of this plan is for the permitting of a / septic system only. DATE: SCALE. Review: PS Comp/Draft: RRL 5.) This plan is only valid with an original February 5 � 2007 1l1=20r Proj ,# 27002 Drawing # C372_3Gi.dwg stamp & signature.