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HomeMy WebLinkAbout0027 PARKER ROAD - Health LSte arker Road: .. ille f t 117 -1621 u r Fee No. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS . 01pplitation for Disposal *pStem Construction permit f. Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon Complete System ❑Individual Components Location Address or Lot No.4- (P*j*0 r? Owner's Name,Address,and Tel.No. Assessor's Map/Parcel (xoeN 112 4 ( jGY'1 Installer's Name,Address,and Tel.No., Designer's Name,Address,and Tel.No. Type of Building:Dwelling No.of Bedrooms Wok Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) . Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) � ,,�(70"z mt-Ny O� C)K j 5�j �y$ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date d f Application Approved by �' Date Application Disapproved by Date for the following reasons Permit No. s�� D�1,� ���. Date Issued OLI t No. C�V 1 �" �.ttd t t .? .. . Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: P_ UBLIC•H,EALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Oplitation forlDispD8al *pstem Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( +}�❑Complete System ❑Individual Components Location Address or Lot No. aY �y Owner's Name,Address,and Tel.No. �4ero ti�e yy r63 Assessor's Map/Parcel C Z ®��aw, Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling -*No.of Bedrooms iV�/i Lot Siz ��`�sq,ft Garbage Grinder( ) Other Type of Building No.of Perso i-ss Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) KI /A gpd Design flow provided Aly Plan Date Number of sheets Revision Date ' Title Size of Septic Tank Type of S.A.S. 5 Description of Soil ' A 4 Nature of Repairs or Alterations(Answer when applicable) Alza8eim me-ru - Q� (r X?SIN nth^ SC"D 1" $}r'1,z Date last inspected: _ Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. r Signe Date e Application Approved by / �'y Date r' Y ` Application Disapproved by Date for the following reasons Permit No. �} pq� Oc tell Date Issued ­7 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance ' THIS IS O CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned(�/by .xK \\ , t a �.'(C�"fib t C06t,t- at � 7 `c At n( vr) n9,e w 11 it. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.202 Q dated / -o� Installer Designer #bedrooms I Approved design flow gpd The issuance of this permit not be construed as a guarantee that the system will funct• as destg l;d. Date } Inspector � . _. No. 1 ^"'{C7� ✓" Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction permit Permission is herebyranted to Construct Upgrade Repair U Abandon.g ( ) P ( ) Pg ( ) ( . ) System located at- ' 7 '?a lc a r �r' O-4r(U I)� e B and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date _`1 f 0 t Approved by ) �-`'�"����a••��,t�/ I �'' Commonwealth of Massachusetts Title 5 Official Inspection Form � I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Parker Rd. Property Address i FALKSON, SHANNON TR t.i Owner Owner's Name / information is required for every Osterville V MA 02655 1/19/21 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 Information1-��- filling out forms on the computer, use only the tab Robert Paolini key to move your Name of Inspector cursor-do not Robert Paolini use the return key. Company Name 67 Tanbark Rd. Company Address Marstons Mills MA 02648 Cityrrown State Zip Code (508)280-9499 S14454 Telephone Number License Number B. Certification 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 listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the local Approving Authority 4. ❑ Fails 1/19/21 Inspect *nature 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. t5in3p.doc•rev.7128/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 27 Parker Rd. u Property Address FALKSON, SHANNON TR Owner Owner's Name information is required for every Osterville MA 02655 1/19/21 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: 2) 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Parker Rd. Property Address FALKSON, SHANNON TR Owner Owner's Name information is required for every Osterville MA 02655 1/19/21 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 :below (Explain ) ❑ 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): 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.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 27 Parker Rd. Property Address FALKSON, SHANNON TR Owner Owner's Name information is Osterville MA 02655 1/19/21 required for every page. Cityrrown 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 ❑ ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Parker Rd. Property Address FALKSON, SHANNON TR Owner Owner's Name information is required for every Osterville MA 02655 1/19/21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than%day flow ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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.7126=18 Title 6 Official tnspocdon Form:Subsurface Sewage Disposat System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Parker Rd. Property Address FALKSON, SHANNON TR Owner Owner's Name information is required for every Osterville MA 02655 1/19/21 page. Cityfrown 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. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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)] t5insp.doc-rev.7/26/2018 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 f cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 27 Parker Rd. Property Address FALKSON, SHANNON TR Owner Owner's Name information is required for every Osterville MA 02655 1/19/21 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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): 550 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® 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 Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 19:16,000 20:12,( Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date t5insp.doc•rev.726=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments V91; 27 Parker Rd: Property Address FALKSON, SHANNON TR Owner Owner's Name information is required for every Osterville MA 02655 1/19/21 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 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? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments u 27 Parker Rd. Property Address FALKSON, SHANNON TR Owner Owner's Name information is required for every Osterville MA 02655 1/19/21 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1 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.): Joints appear tight. No evidence of Ieakage.System vented through house vents. t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 f— c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 27 Parker Rd. Property Address FALKSON, SHANNON TR Owner Owner's Name information is required for every Osterville MA 02655 1/19/21 page. City/Town State Zip Code Date of inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5' feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 GI. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 39» Scum thickness 1" 8, Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 10" 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 every two years.Inlet and outlet tees in place.No signs of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form FI Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Parker Rd. Property Address FALKSON, SHANNON TR Owner Owner's Name information is required for every Osterville MA 02655 1/19121 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 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: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Parker Rd. Property Address FALKSON, SHANNON TR Owner Owner's Name information is required for every Osterville MA 02655 1/19/21 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): 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 level No signs of leakage.Box has four outlet laterals. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 27 Parker Rd. u Property Address FALKSON, SHANNON TR Owner Owner's Name information is required for every Osterville MA 02655 1/19/21 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.): * 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: 4 LC 500 Cl leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 v c� Commonwealth of Massachusetts F Title 5 Official Inspection Form - FIe Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Parker Rd. Property Address FALKSON, SHANNON TR Owner Owner's Name information is required for every Osterville MA 02655 1/19/21 page. 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.): Sandy soil.No signs of hydraulic failure. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7126/2018 We 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form � 1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Parker Rd. Property Address FALKSON, SHANNON TR Owner Owner's Name information is required for every Osterville MA 02655 1119/21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): I t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Officiai inspect onForm WE Subsurface.Sewage,Disposal Syst®m Form-Not for'Voluntary_Assessments 21 Parker Rd. Property Address. FALK$W$44!NON TR, Owner Owner's Name information is. required for;every, Oster . ville MA 02655 1/19/21`. page:. City/Town. State. Zip Code. Date of Inspection D. System Information (cont.) 1:4. Sketch Of.Sewage Disposal SysteM: Provide a view of'4he swage disposal system; including ties to at least two permanent reference: landmarksor benchmarks. Locate all wells within 100 feet:tocate where public water supply enters the building-Chock one of the.boxes below: hand-sketch in`the-area below D drawing attached separately 0. r, 1 h9/2021.,: c Commonwealth of Massachusetts Title 5 Official Inspection Form nIo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u� 27 Parker Rd. Property Address FALKSON, SHANNON TR Owner Owner's Name information is required for every Osterville MA 02655 1/19/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water W Check cellar ❑ Shallow wells Estimated depth to high ground water: 10'above adj. groundwater 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 r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 7 , c Commonwealth of Massachusetts Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Parker Rd. Property Address FALKSON, SHANNON TR Owner Owner's Name information is required for every Osterville MA 02655 1/19/21 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 ® 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.7/26t2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 PARKER RD. Property Address OPTION 1 MTG. CO. Owner Owner's Name information is required for OSTERVILLE MA 02655 5/29/07 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. �J 73 Important: A. General Information When filling out forms on the computer,use 1: Inspector: only the tab key ✓ to move your VANCE STEVE YOUNG cursor-do not Name of Inspector use the return key. Company Name BOX 1592 Company Address MANOMET MA 02345 Cityrrown State j Zip Code 508 224 8332 N/A Telephone Number License Number B. Certification -� Ca ='' I certify that I have personally inspected the sewage disposal system at this add ess and�that tiTB information reported below is true, accurate and complete as of the time of the i spectic%Th inspection was performed based on my training and experience in the proper function and aintenance ..on site sewage disposal systems. I am a DEP approved system inspector pursuant to Sec ion 1 m340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/29/07 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 27 PARKER RD.•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 27 PARKER RD. Property Address OPTION 1 MTG. CO. Owner Owner's Name information is OSTERVILLE MA 02655 5/29/07 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cost.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)in the❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfittration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 27 PARKER RD.•08/06 Title 5 OfftW lnspecton Form:Subsurface Se+age Disposal Page 2 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M s 27 PARKER RD. Property Address OPTION 1 MTG. CO. Owner Owner's Name information is required for OSTERVILLE MA 02655 5/29/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 heatth,.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 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. 27 PARKER RD.-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 27 PARKER RD. Property Address OPTION 1 MTG. CO. Owner Owner's Name information is required for OSTERVILLE MA 02655 5/29/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria 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 Yz day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high 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. 27 PARKER RD.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 27 PARKER RD. Property Address OPTION 1 MTG. CO. Owner Owner's Name information is required for OSTERVILLE MA 02655 5/29/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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. 27 PARKER RD.-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 PARKER RD. Property Address OPTION 1 MTG. CO. Owner Owner's Name information is required for OSTERVILLE MA 02655 5/29/07 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)] 27 PARKER RD.•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 'p 27 PARKER RD. Property Address OPTION 1 MTG. CO. Owner Owner's Name information is required for OSTERVILLE MA 02655 5/29/07 every page. Cityfrown State Zip Code Date of Inspection 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 Number of current residents: 0 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)): N/A Sump pump? ❑ Yes ® No Last date of occupancy: 3/1/07Date 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: Last date of occupancy/use: Date Other(describe): 27 PARKER RD.-08106 Title 5 Official Insp ection frorrn:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 27 PARKER RD. Property Address OPTION 1 MTG. CO. Owner Owner's Name information is required for OSTERVILLE MA 02655 5/29/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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/Altemative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2YRS PER AS-BUILT DATED 8/15/05 Were sewage odors detected when arriving at the site? ❑ Yes ® No 27 PARKER RD.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 PARKER RD. Property Address OPTION 1 MTG. CO. Owner Owner's Name information is required for OSTERVILLE MA 02655 5/29/07 every page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Building Sewer(locate on site plan): Depth below grade: 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: .5 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 10X5X4 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 0 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 18" How were dimensions determined? MEASURED 27 PARKER RD.•G&G6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•rage 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �,M ,•''r 27 PARKER RD. Property Address OPTION 1 MTG. CO. " Owner Owner's Name information is required for OSTERVILLE MA 02655 5/29/07 every page. Cityfrown 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.): INLET AND OUTLET TEES OK..STRUCTURAL INTEGRITY OK. LIQUID IS LEVEL WITH OUTLET INVERT.NO SIGNS OF BACK-UP OR LOADING 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i 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): 27 PARKER RD.•08106 TAle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 27 PARKER RD. Property Address OPTION 1 MTG. CO. Owner Owner's Name information is required for OSTERVILLE MA 02655 5/29/07 every page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cunt.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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 LEVEL AND DISTRIBUTION IS EQUAL-STRUCTURAL INTEGRITY OK NO SIGNS OF BACK-UP OR SOLIDS CARRY-OVER Pump Chamber(locate on site plan): Pumps In working order: .;, ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 27 PARKER RD.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 27 PARKER RD. Property Address OPTION 1 MTG. CO. Owner Owner's Name information is required for OSTERVILLE MA 02655 5/29/07 every page. City/Town state Zip Code. Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) pocate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ 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.): SOIL IS VERY DRY IN THE AREA, NO SIGNS OF FAILURE 27 PARKER RD.•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 15 h Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 27 PARKER RD. Property Address OPTION 1 MTG. CO. Owner Owner's Name information is required for OSTERVILLE MA 02655 5/29/07 every page. Citylrown State Zip Code Date of Inspection D. m cont.System Information i n o at o (cont.) . 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 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.): 27 PARKER RD.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 PARKER RD. Property Address OPTION 1 MTG. CO. Owner Owner's Name information is required for OSTERVILLE MA 02655 5/29/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 7 . y3� ;I O � 5; i 27 PARKER RD.-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 PARKER RD. Property Address OPTION 1 MTG. CO. Owner Owner's Name information is required for OSTERVILLE MA 02655 5/29/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: g+feet Please indicate all methods used to determine the high groundwater elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 8/15/05 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: AS PER AS-BUILT ON FILE 27 PARKER RD.-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 TOWN OF BARNSTABLE "22 Pa&Kef (4 SEWAGE # VILLAGE 0 sTc,'vi l( e ASSESSOR'S MAP & LOT 117 Ic�Z I'nsPcc.ivr� p.�� MT-AbhEWS NAME&P 746G- SEPTIC �I LEACHING FACII.TTY: (type) !Z4G4 P,, (size) �O X b w�z s7o^e NO. OF BEDROOMS BUILDER OR 00 ��PERMTTDATE: 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 e mme-M S Ilgy �• �. w�� of � , P;t �� � � � � i a� �� I � -`�� a �� � 1 � �� b � � �. l F��t r TOWN OF BARNSTABLE LOCATION -?7 / f--?X-411 /W SEWAGE # 28—3<� VILLAGE % GG ASSESSOR'S MAP & LOT L/ .e,2 L-� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY .7 c'o e,-s.�17� 445sae""4s cj- 7jgF .4L LEACHING FACELrrY: (type) pIT (size) 4-xC /�lT tifNO.OF BEDROOMS ,BBiM�OR OWNER &XV. jDY"-X .r ham✓✓/.-%ems PERMITDATE: 4a'V ; COMPLIANCE DATE: 4,�?Z2, Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or.within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by / /�� rim A. '� j �� ���� , 0� _ �iT � ` � � "'3 � � � � i � yr �` I� i I I \ i � \ � -� 1=Rotit TOWN OF BARNSTABLE LO(CATICN SEWAGE VILLAGE ASSESSOR'S MAP & LOT — -2 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ZOCyl �.P6•w) (size) NO.OF BEDROOMS BUILDER OWNER PO4 PERMITDATE: 7:1,&-,ar 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 o a ' s Y+1o. Fee 7 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes •; PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZppYication for Oioponl *pgtem Cott!5truction Permit Application for a Permit to Construct( )Repair(1/)Upgrade( )Abandon( ) &/Complete System ❑Individual Components Location Address or Lot No. 7,7 Gl l)- •pin Owner's Naame.,.Add ss and Tel.No. Ass is Map/P c 1 ,1/V C Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. APle Type of Building: Dwelling No.of Bedrooms Lot Size I sq.ft. Garbage Grinder( � Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow I,jC _� gallons per day. Calculated daily flow 461 gallons. Plan Date D Number of sheets / Revision Date Title Size of Septic Tank / �� Type of S.A.S. ` /d pox 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 o d of ealth. Signed Date Application Approved by Date �� 5 Application Disapproved for the following reasons Permit No. a00 5 3 '1 S Date Issued - -5V p�� �: .,� .� � ..� ...+....,...ter ti,+• � i ?No.r r; Fee ' '''T E COMMONWEALTH OF MASSACHUSETTS Entered in computer: ' Yes ' PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLES MASSACHUSETTS _ Ycation forigo�aYp�.ten� Construction Permit Application for a Permit to Construct( , )Repair( V)Upgrade( )Abandon( ) QComplete System ❑Individual Components Location1. p°Sr Address or Lot No. f^�/��✓` y Owner's Name,Address and Tel.No. r Ass so;'s—Map/P�r4l i Installer's Name,4ddress,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: 9 Dwelling No.of Bedrooms S Lot Size 2 sq.ft.. Garbage Grinder Other Type of Building .�5� z"�CC'No. of Persons Showers( ) Cafeteria( ) ; Other Fixtures �— Design Flow t-/^ 3�_o gallons per day. Calculated daily flow gallons. Plan Date 7/� 49_ _ Number of sheets Revision Date Title S -51If 41-*'167/I a 2,1;' Q/,��,►'' �'G� Size of Septic Tank �a Type of S.A.S. L/- -. 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 Codee and not to place the system in operation until a Certifi- cate of Compliance has been isW d by th's oard o -ealth: Signed Date 7` Application Approved b Date J� PP PP Y Application Disapproved for the following reasons Permit No. a UU 5 .3 V 5 Date Issued a THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CER FY, that the On-site Sewa eyDisposal System Constructed ( ) Repaired Upgraded( ) Abandoned )by, at Z 7 ��� � r ��U�^ �� has been constructed,in accordance with the provisions of Title 5 and the for Nposal System Construction Permit No,.c0.00 J 3`4--5 dated 7AW d Installer `` �' � Designer The issuance of this per t s all n9t be construed as a guarantee that the system ill unction a esigned. Date Inspector — No. �. ---.----------- f--'---.-----Fee tJ 4 .. .. . . ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 1=i!5Po!a1 *pgtem Construction Permit Permission is hereby granted to Construct.(. )Repair(�U rade( )Abandon System located at 'l�r, r le and as described in the above Application for Disposal System Construction Permit. The.applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Constrc 'on must be completed within three years of the date of this p• ; .it. Date: G Approve- bye.___ v FROW :down cape engineering inc FAX NO. :15083629880 Aug. 25 2005 09:34AN P2 Town of Barnstable Regulatory Services Thomas F. Geiler, Director • Lts2vsreet�. � Publics Health Division t6aq. �� 6nr ` Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Desizner Certification Form Date: 11 ZJ`05 Sewage Permit# $— Assessor's Map\Parcel h ` 167'1� /JDesigner: J(IInstaller: Aeyr_- �-D 110 AC,601_ , Address: N ✓� i�-- Address: /P�• 166 Yarmu►tiT``J It'� Q•►�c/ r /tli4 on -71WI05— ®/'140111i'��16 was issued a permit to install a (date) (installer) septic system at oZ 7 ��- 40a,:4 based on a design drawn by (address) N d dated \T, " / (desi ner) V v w substantially I certify that the septic system referenced above as Installed substan ally according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes i.e greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State.& Local Regulations. Plan revision or certified as-built by designer to follow. �jrt OF Mks ARNE H yGs (Installer's Signature) o OJALA 0 CIVII. �n No. 30792 e oT E-Q'e (Designers Signature) (Aff Offinp Here) PLEASE RETURN TO $ARNSTABi,E PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUFlD UNTIL BOTH THIS FORM_AND AS-BUILT CARD ARE RECEIVED BY THE BAR STABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Hcalth/Septic/Dcsigncr Certification Fomi 3-26-04.doc I� = I f S CL COMMONWEALTH OF MASSACHUSETTS Z W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a d DEPARTMENT OF ENVIRONMENTAL PROTECTION � < Ads F��CJ °"gym �a�M Ste "A F ® ¢ - PECTION MAY 2, 4 2005 --wee.a..lY.wM.n+v.Y^n1a. TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: #27 Parker Road Osterville,MA Owner's Name: Jody Pollich Owner's Address: 27 Parker Road Osterville,MA Date of Inspection: 4/27/05 Name of Inspector: (please print) Mr.Carmen E. Shay Company Name: CAPEWIDE ENTERPRISES,LLC Mailing Address: P.O.Box 763 Centerville,MA 0632 Telephone Number: (508)-428-4028 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes HOFM,gS Conditionally Passes Needs Further Evaluation by the Local Approving Author... o� CARMEN tiG XX Fails N E. SHAY Inspector's Signature: Date: 4/27/05 °FgT�F��4)Q 0 �FS MSPE� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of H DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments Liquid level over inlet invert of both leach pit and cesspools. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: #27 Parker Road Osterville,MA Owner: Jody Pollich Date of Inspection: 4/27/05 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: __ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to abroken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: .,.., 2 � _ I f Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #27 Parker Road Osterville,MA Owner: Jody Pollich Date of Inspection: 4/27/05 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: IL - - Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #27 Parker Road Osterville,MA Owner: Jody Pollich Date of Inspection: 4/27/05 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No XX. _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool XX Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped XX Any portion of the SAS,cesspool or privy is below high ground water elevation. XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. XX Any portion of a cesspool or privy is within a Zone I of a public well. XX Any portion of a cesspool or privy is within 50 feet of a private water supply well. XX Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] YES (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. r Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: #27 Parker Road Osterville,MA Owner: Jody Pollich Date of Inspection: 4/27/05 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No XX Pumping information was provided by the owner,occupant,or Board of Health XX Were any of the system components pumped out in the previous two weeks? XX _ Has the system received normal flows in the previous two week period? XX Have large volumes of water been introduced to the system recently or as part of this inspection? XX _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) XX _ Was the facility or dwelling inspected for signs of sewage back up? XX _ Was the site inspected for signs of break out XX Were all system components, excluding the SAS, located on site? XX _ 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 ? XX _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no XX _ Existing information.For example,a plan at the Board of Health. XX _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: #27 Parker Road Osterville,MA Owner: Jody Pollich Date of Inspection: 4/27/05 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no):_ Seasonal use.: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2002— 110,000 gallons Sump pump(yes or no): No 2001 — 113,000 gallons Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unknown Was system pumped as part of the inspection(yes or no): If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM XX Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: April 22, 1978 per Board of Health&Owner Records Were sewage odors detected when arriving at the site(yes or no): No 6 r y Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #27 Parker Road Osterville,MA Owner: Jody Pollich Date of Inspection: 4/27/05 i BUILDING SEWER(locate on site plan) Depth below grade: 16" Materials of construction:__cast iron XX 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): No evidence of leaks or damaged piping. Venting noted on roof. No odors noted. SEPTIC TANK: XX (locate on site plan) Depth below grade: Material of construction: XX concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 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: 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.): GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #27 Parker Road Osterville,MA Owner: Jody Pollich Date of Inspection: 4/27/05 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: Not Present (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no):_ Comments(note condition of pump chamber,condition of pumps and appurtenances, etch_ L Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #27 Parker Road Osterville,MA Owner: Jody Pollich Date of Inspection: 4/27/05 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type XX leaching pits,number: 1—6 x 6 pit with 2 feet of stone around_ leaching chambers,number: leaching galleries,number: leaching trenches,,number, length leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Significant evidence of hydraulic failure. No ponding damp soil or stressed vegetation Probed stone with evidence of hydraulic failure. Liquid Level over inlet invert. CESSPOOLS: 2 (cesspool_ _( po must be pumped as part of mspection)(locate on site plan) Number and configuration: 1 Primary Acting as a Septic Tank and one Overflow Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (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.): .„., 9 Page 10 of 11 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #27 Parker Road Osterville,MA Owner: Jody Pollich Date of Inspection: 4/27/05 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. p t eR �l 01 Page 11 of 11 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #27 Parker Road Osterville,MA Owner: Jody Pollich Date of Inspection: 4/27/05 SITE EXAM Slope Surface water -None Check cellar -Yes Shallow wells—None Estimated depth to ground water 15' feet below grade. Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: XX 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) XX Accessed USGS database-explain: _ You must describe how you established the high ground water elevation: checked with Quadrande of USGS Map. Estimated Elevation above Sea Level at 15 feet Inspector has performed Pere tests in this area. i� ,l ���a t� OD No. 9- l�t�7QW�7 F SWP ! Fee THE COMIfIWTH OF MASSACHI! S/� . PUBLIC HEALTH DIVISION -TOWN OF B s ASSACHUSETTS 01pplication for Migaal *pgtem Congtruction permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. A--� - hh . 0SLY-'J k... :!:�) �q C_- A` Installer's MA ddress,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil �y, )s C_ Nature of Repairs or Alterations(Answer when applicable) -� i r Date last inspected: l 1 qqs 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 is e``--b''y this Board of Health. Signed a;IZ4� �` Date l/—)'I—l 9?I Application Approved by Application Disapproved for the following reasons Permit No. '° �' J Date Issued___ / 1 " 13'-'/I'K i t 'No. " /lay e THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEs ASSACHUSETTS ' 6� 4 Zlpplication for Migponl 6pztem Cougtructiou Permit Application is hereby made for a Permit to Construct( )or Repair( )'an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. -Po, q,b ty"i �,k� c Installer's N e,Address,and Tel.No. Designer's Name,Address and Tel.No. 1'6s 4ZA ,t'�o Mo 54. oj�Pef. 'M, . Cru_�� -o• ��1e r..�c�h:c_��S , Type of Building: i Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title c Description of Soil c, i Y Nature of Repairs or Alterations(Answer when applicable) . tt � r { 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- cateof Compliance has been is e�by tho Board of Health Signed �Cl�-�l �` Date -1 3-i g 91" Application Approved by Application Disapproved for the following reasons 1 Permit No. Date.Issued i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISIONARNSTABLE, MASSACHUSETTS Certificate of Compliance - ThIIS IS TO CERTTFY,.th the On-s'te Sewage Disposal System instal edr repaired/eplaced( )on oZ j YLZt�`" 1�11, E)S by cc�c t w w� r I CKS , for t 1'a �`e w t- as W h h bee constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N dated Use of this system is conditioned on compliance with the provis1 set forth below: t THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ae Mioaal *pgtem Construction Permit Permission is hereby granted to C,, "`^ ��w d r- c c S- to construct( )repair(L„4-mMn-site Sewage System located at In -, and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: N C Approved b - — F n^ ���^..... ..................... THE COMMONWEALTH OrMASsAc*ueErrs ������ U� ��=~ ' ����,=� . . �°-=,��°=--- »° ��^°��='", ^ � ��°~ °� ����/��lurx�t u� �u���� �p�xn�xu���m� Works *funf»u4u4rt�mn ramKt Application is hereby made for u Permit to Construct ( ) or Repair ( °T xo Iod6Qual Sewage Disposalation- ddr"ess or Lot No. Wn Address ......... ....J.,a: . .' -----------_------'----..--_-_---________________. � InstallerAddAddressPQ � ^" " Type of ` Size So feet U Dwelling--No of Attic ( ) Grinder ( ) Other—Typeof Building ---------------------------- No. of persons............................ Showers ( ) -- Cafeteria ( ) Otherfixtures -------- ................................................................................ Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid ............gallons Length................ Width................ Diameter----.-' Depth----.--. D�uoau Trench--No. -'-------' \�il8�-----.--' Iotu I.cugtb-------'- Totu leaching area....................sq. f t. Seepage Pit No--------------------- Diameter----. ...... Depth bdmviold--------- Tota leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) '- Percolation Test Results Performed by.......................................................................... Dutc-----------------' Test Pit No. l................noioutcsperiuc6 ]}cptb of Test Pit----.----' Depth to ground vvotoc-.-----._.. IX4 Test Pit No. 2................minutes per inch I}ent6 of Test PiL-_.-----_ Depth toground water........................ � 9 ........................................................................................................................................................... 0 Description of Soil.....................................................................................................---------------------------------------_---'-__-_- ................................................................................................................................................................................. o; ~-~�=�^-'-��,~*~�y^.-.--~~~~��~~---°~-.-- �~�~�^~====~~--_~~------'---_ ' me A:/ee nt The ��� �� a����r�cd Iod��6n� S��u� D�»poy� Sy��m � a�o��� �� | . ~ the provisions of'LI'xT 5c6 the State operation until uCertificate of Compliance has en sue by,the bo d iea t/ -~n -_---��'-- -----_--- `~ ~-��"�" ------- Application Approved 8y.......................... ��-�,���,�� ,---.-------------'- ' Da" Application Disapproved for the following reasons:.............................................................................................................. ........................................................................................................................................................................................................ � Date � Permit »� '.--------'--------'-_-----'---- Issued....................................................... T7 r. ell% No....................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H.EAI=TH ........... ........................... Appfir,athm for U44paiial Vorko Tomitrurtion ramit ' Application.is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Syst a -------------- .................................. .............................. -7­7 ation-Ad ress or Lot No. • W Address .................................................................................................. Installer Address Type of Building �,,�Size Lot............................Sq. feet U Dwelling—No. of Bedro omsib,3................................Expansion Attic Garbage Grinder (Other—Type of Building ............................ No. of persons__.__..._..__._..____.__.._. Shower.s> Cafeteria ( Other fixtures .........1� ............................................. ...................... ............................................... Design Flow...................................... gallons per person per day. Total daily_A_0*�........... ...._________________________gallons. Septic Tank—Liquid capacity....... gAllbn�'­�",Length--------41..... Width.._........I..... Diameter�, Depth ............. ....- ILength..____._.__._____._. . g.......... Disposal Trench—No..................... wf& " �.......... ......Total T�,taljeachid area-------------_----sq. ft. �Tot he ­� area..................sq. ft. Seepage Pit No_____________________ Diameter..... Depth belowInlet.................... a achi z Other Distribution box Dosing Percolation Test Results Performed by- ........ 4.................................... Date______________________________.:_____- Test Pit No. I________________minutes perinch Depth of',' est ............ Depth to gr�und water___._._..__.____._.____. 0-4 Test Pit No. 2................minutes per inch Depth of Test'Pit___.....___._._.____ Depth to groun&We' r........................ ............................................................................................................................... .... D P h escrition of Soil...................................................................................... ................................................................................. U ....................................................................................................................................................................................... ...................................................................................... ............... .......... ........... . ....�:P. Natury of Repairs or Alterati when applica lee-- U 0 A s;7 ........... .......................... 1-C Aeeement: —A The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T'IT LZ 5 of the State Sanitary se The undersigned further rees not to place the system in . — I' r ee operation until a Certificate of Coffipliance has l en led b,- the board ghhe�/a Si hd_.�.. ....... ...... .. ...................gne.. . .......... . !,/---- ---...... ................. 7 1�— ate ApplicationApproved By.......................... .................................................................... Date Application Disapproved for the following reasons__ _________________________________________________________ f_j._______ ............................... ..................................................................................................7------------------------------------------------------------- ................................... Date ...... Issued-'(. ..........................................Permit No....................................................P Date THE COMMONWEALTH OF Mk5SACKOVE�TS BOARD OF HEALTH .....OFe.V ......................................................................... Trrfifiratt of Tompliana T CL TIFY, T t the In(yv4al Sewage Disposal System cons6uctedlq, or Rpaired by------ ------ .. . ...... . ..... ................................................ .... . ..........Voe......................I------------------ ........... r Installer i I I . "I i;�,, at- -- ___-- _-- ..... ................................*--- --- --- ----- ........ --------- ....*--------------*........................... has been installed in accordanceprovisions I � r f with the of T � ).QJ e State Sanitary Code as descyibfd in the application for Disposal Works Construction Permit No.__ ...... ....................... dated__.. ";2 A — #Ili-- ------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL"hOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SAYJSFACTORY. DATE........ —3 .................................................................... Inspector_,�.�...........:�------ -------------------------------------------- T1tE.COM'MONWEAL-7H%,,PF MASSACHUSETTS BOARD'tA?F HEALTH 'S 6F.0 R w ,,,, ... �.. ............ ..................................... FEE......................... ....... 414P:1 4�' N Disposa ork Tons Toais#ra riwit pamit Permission-1s hereby granted..:... ......... .. ........................................................................................................... to ConstrugS o pair A an; ,A�osal System i Wiv*.dual SeA;� ............ at No....4K . . .. .......................................................................................... .. -7 Street P as shown on the application for Disposal Works Constrpction Per ........ ted.i��... Board of Health DATE. . . ......................... ............. ........................... FORM 1255 HOSES & WARR;EN, INC., PUBLISHERS TOP FNDN. AT EL. 37.9' SYSTEM PROFILE TEST HOLE LOGS ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) PROVIDE INSPECTION PORT WITHIN R ACCESS COVER (WATERTIGHT) TO 6" OF FINISH GRADE ENGINEER: LISA LYONS, RS /36.3' MINIMUM .75' OF COVER OVER PRECAST /� WITHIN 6" OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 36.2 WITNESS: ? 2" DOUBLE WASHED PEASTONE\! DATE: JULY 6, 2005 OA I_ RUN PIPE LEVEL 2 MIN/INCH 36.6'f* FOR FIRST 2' 3' MAX. PERC. RATE - PROPOSED 1500 rp GALLON SEPTIC 34.0' H-2o 33•2' 1 11037 34.25' CLASS SOILS P# BAY TANK (H- 10 ) GAS'._ BAFFLE 32.79' �oo �M�- , a 0 a 0 0 O Ci I� LOCUS 3IN 2.37 0 0 Cl 0 .Cl L 7 C7 CI C' o ( M2 % SLOPE) t___ B" CRUSHED STONE & MECHANICAL 771 17-1 1-7-1 0 17-1 0 Q: Ill Q ,l " ELEV. COMPACTION. (15.221 [21) MIN 2' ic o = E7a r7 r- pm o 30.37 B 36"0' �g' DEPTH OF FLOW = `4 ( 6 1% SLOPE) ( % SLOPE) 3/4" TO 1 1/2" DOUBLE WASHED STONE LS TEE SIZES: Of INLET DEPTH 1 p�� 14 H-20 CHAMBERS a ' 10YR 5/6 OUTLET DEPTH = 14 Cl LOCATION MAP NTS F/MS FOUNDATION 20' SEPTIC TANK 19' D' BOX 27' LEACHING FACLITY 6 37' 459p 2.5Y 6/4 ' ASSESSORS MAP 117 PARCEL 162 *THE INSTALLER SMALL VERIFY THE 5 LOCATIONS OF ALL UTILITIES AND ALL C2 BUILDING SEWER OUTLETS AND ELEVATIONS PRIOR TO INSTALLING ANY PORTION OF N FS SEPTIC SYSTEM 2.5Y 7/4 o PROVIDE VENT WITH CHARCOAL FILTER 24•0' 80" 0 AND BUGSCREEN (FINAL PLACEMENT WITH C► Epp 45, HOMEOWNER CONSULTATION) C3 ** INSTALLER TO PERFORM ADDITIONAL •j-Z5.38 BAND OF FSL 80" - 88" ON SOUTH TEST HOLE AT OTHER END OF 35. 69 MS WALL OF TH ** PROPOSED SAS AT TIME OF 9 •5Q> 35.38 a$- RRT1Fg 46,Og' INSTALLATION TO CONFIRM SUITABLE / WALL OF TBAND OF H**00" - 110" ON NORTH NOILS. CONTACT TALLAT ON OF ANYENGINEER COMPONENTS TO TO 1 39 b 3�.3i 68 98 2.5Y 5 4 INSPECT SOILS TH C9 p• 35.74 - 8-F 3b�2>3 ' '}• .Q 7+38.72 NGWE J STONE 6' 36.3 - 6.42 77 NOTES. 1 =}-36.58 -I-�6.2� VED �•�8.37 - DRIVEWAY 36.26 _ -li3 6• 4 37" OAK ,48 36.6 6.90 ,73 ` 1 -3 ,97 16" M P 66.27 40' CROWNP3,85SEPTIC DESIGN: APPROX. NGVD OLE FLAG 6.55 (GARBAGE DISPOSER IS NOT ALLOWED ) - 1. DATUM IS c 6'. i ;.,8 ,�-ci�Ra ri ant• 5 n �i� S 110 r'A _ r` EXISTING COBBLE. W Rti � _.jIiN . _O:q: -_ BEDROOMS. � { ,• D) 550 aD � kWkllr'lD 'I %AIA-rr7P !'; AT EDGE I+ 6.24 0 JG 39 J. USE A 550 GPD DESIGN FLOW 3. MINIMUM FIPE PITCH TO BE 1/8" PER FOOT. LOT 1 36. 1 0 6ss SEPTIC TANK: 550 GPD (2) = 1100 4. DESIGN LOADING FOR SEPTIC TANK TO BE AASHO H- 10 ^�-.. 4 6.5 6.81 3 w 1500 DESIGN LOADING FOR D'BOX & CHAMBERS TO BE AASHO H- 20 26,000 SFt �'' `-+36,46 ATERUNE USE A ____ GALLON SEPTIC TANK 17 5. PIPE JOINTS TO BE MADE WATERTIGHT. 35.�4Il�H � � DECK 37�a .96 //J�� LEACHING: 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE OND 36.84 G WITH MASS. 37 +I 6,90 36.01 •0�© SIDES: 2(49 + 10.83�2 (.74�_ = 177 ENVIRONMENTAL CODE TITLE V. 6 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT 15 •32 Q -I-39:00 49 x 10.83 (.74) = 392 EXISTING 37.28 39 BOTTOM: TO BE USED FOR ANY OTHER PURPOSE. 3 .47 DWELLING(7) 769 569 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. . / +37.30 O 4 7.38 TOP FNDN. =37.9' BENCHMARK TOTAL: S.F. GPD LAB CDR BR. LANDING Q USE (4) 500 GAL. H-20 LEACHING CHAMBERS WITH 3' 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT EL=38.o' , Q- INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED + M Q STONE AT ENDS, SIDES AND BETWEEN CHAMBERS �,30 / �� � FROM BOARD OF HEALTH. DECK 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) EXISTING SEPTIC SYSTEM GAS 37.69 ,// qS S 3 , Q� LEGEND TITLE 5 SITE PLAN N / SLEEVE SEWER LINE FROM DWELLING / 100.0 PROPOSED SPOT ELEVATION OF TO PROPOSED SEPTIC TANK 3 8 27 PARKER ROAD 100xO EXISTING SPOT ELEVATION IN THE TOWN OF: 0 100 PROPOSED CONTOUR ( OSTERVILLE) B A R N S TA B L E 100 EXISTING CONTOUR PREPARED FOR: BORTOLOTTI CONSTRUCTION/POLICH 20 0 20 40 60 BOARD OF HEALTH APPROVED DATE MA SCALE: 1» = 20' DATE: JULY 9, 2005 off 508-362-4541 fax 508 362-9880 down cape engineering, inc. ��� AHNE AR H. OJALA i N CIVIL CIVIL ENGINEERS �P40 26348 > o• LAND SURVEYORS Ess%o 'aOO 05- 156 939 main st. yarmouth, ma 02675 ARNE H. OJALA, P.E., P.L.S. DATE