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HomeMy WebLinkAbout0268 PARKER ROAD - Health 268' Parker,P�0'P Osterville . P A - 116 "132 l G i II Commonwealth of Massachusetts Title 5 Officials Ins ection Form a Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments ments 268 Parker Road Property Address Joan Lan enber Owner information is Owner's Name required for every Osterylllee MA 02655 10/16/13 . page. Cltyfrown State -ZIPCode 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. General Information filling out forms , on the computer, use only the tab 1 Inspector: key to move your cursor-do not James Ford ( ' �14 �3,� use the return J key. Name of Inspector U1.6 Company Name . P.O. Box 49 CAompany Address , '" Osterville MA City/Town 02655 State Zip Code 508-862-9400 S 12482 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally-Passes ❑ Fails Needs Further v luation by the Local Approving Authority i 10/16/13 Inspe is Signature Date If, The tem inspectorshall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. *'*"This report only describes conditions at the time of inspection and under the;conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3l13 ' Title 5 Official Insp ltioForm:Subsurface Sewage Disposal System•Page 1 of 17 . Commonwealth of Massachusetts N W Title 5 Offici ail-Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments M 268 Parker Road Property Address Joan Lan enber Owner Owner's Name information is required for every Osterville MA 02655 page. Cityrrown 10/16/13 State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check'A,B,C,D or.E/always complete all of Section D A) System Passes: ; r . ® 1 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:. l a, i B) System Conditionally.Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will{:pass. Check the box for"yes", "noll or not determined"(Y, N, ND)for the following statements.'If"not determined," please explainr The septic tank is metal andlover 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial iAfiltration 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 Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5lns•3/13 dal li rr Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 ii , Commonwealth of Masoachusetts H i Title 5 Offi callnspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments 268 Parker Road Property Address Joan Lan enber 1: Owner information is Owner's Name required for every Osterville page. City/Town MA 02655 10/16/13 ; I} State Zip Code Date of Inspection B. Certification (cont )' ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if Pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage"backup or break out or high static water level in the distribution box due to broken or obstructed pipes)or due to a broken, settled or uneven distribution box. System will pass inspection,if(with„approval of Board of Health):, ❑ broken pipe(s)are.replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box Is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): i . ❑ 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 pipes) re,replaced ❑ Y ❑ N ❑ ND(Explain below): . i' . ❑ obstruction is removed -❑ Y ❑ N ❑ ND (Explain below): ,l C) Further Evaluation is F eyuired 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. I. 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 pnv is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh i5ins•3/13 q Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official 'Inspection For Subsurface Sewage Disposal System Form Not for Voluntary Assessments i 268 Parker Road Property Address Joan Lan enber Owner information is Owner's Name required for every Osterville i' MA 02655. 10/16/13 page. Cityf I Own State Zip Code Date of Inspection B. Certification (cont.)' a 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 aseptic 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: ,Il , **This system passes if the:well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria'are triggered.A copy of the analysis must be attached to this form. 3. Other: T _ j. j D � I: ) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or o"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 ari overloaded or clogged SAS or cesspool ® Static l:rgiiid 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 l5ins-3/13 ti Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 drj Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments `M 268 Parker Road Property Address Joan Lan enber Owner Owner's Name information is required for every Osterville MA 02655 page. C1 own 10/16/13 State Zip Code Date of Inspection B. Certification (cont.) : t Yes No VV� ° ❑ ® Required pumping more than 4 times in th e 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 potion of cesspool or privy is within 100 feet of a surface water supply or tributary o a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. portion of a cesspool or privy is less tha ® Anyn 1'00 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 laborahtory,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- 10,0009Pd El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system=owner should contact the Board of Health to determine what will be necessai)�to correct the failure. i E) .Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to115,000 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 ❑ El 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 31 Q';CMR 15.304. The system owner should contact the appropriate regional office of the Departr l ent. h t5ins•3/13. t a Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official, Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 268 Parker Road Property Address r. Joan Lan enber ' Owner Owner's Name information is j required for every Osterville ' MA 02655 page. Cityrrown 10/16/13 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 i ® ❑ 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 these,stem received normal flows in the previous two week period? l �. uk ❑ ® Have large volumes of water been introduced to the system recently or as part of this inssp�ection? ® ❑ Were as built plans of the system obtained and examined? they were available;note as N/A) ( Y e not ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was thg site inspected for signs of break out? I, ® ElWere al 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 th6facility 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: ® ElExisting information. For example, a plan at the Board of Health. ® ❑ Determiied in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Inform_ atior . Residential Flow Conditions: Number of bedrooms (design)y., 5 -CM Number of bedrooms (actual): 5 FI � . DESIGN flow based on 310 R 15.203.(for example: 110 gpd x#of bedrooms): . 550 ,Sins•V13 i! Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 OfficiallInspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M a 268 Parker Road Property Address Joan Langenber Owner Owners Name information is required for every Osterville r MA 02655 10/16/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: SI i I'g i C Number of current residents 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes No Laundry system inspected?,,,' ❑ Yes ® No Seasonal use? 'i ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: #' unavailable 99 Sump pump? El Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flown 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? f ❑"Yes ElNo Industrial waste holding tank,present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 t _ i i 9 Commonwealth of Massachusetts = Title 5 Official,:-:Inspection Form Subsurface Sewage Disposal,System Form -Not for Voluntary Assessments °M 268 Parker Road Property Address f Joan Lan enber Owner Owner's Name , information is required for every Osterville l i+ MA 02655 10/16/13 page. City/Town State Zi Code P Date of Inspection D. System Information (cont.) Last date of occupancy/use Date Other(describe below): ,; qq 1 General Information' Pumping Records: Source of information: ; `± pumped a couple of years ago Was system pumped as part of the inspection? I ® Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? . -I 9 Reason for pumping: maintenance 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) tr , ❑ 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): 15ins•3113 Title 5:Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 4 Commonwealth of Massachusetts Title 5 OfficiahIns ection For a p m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' l - °� 268 Parker Road M v Property Address Joan Lan enber Owner Owners Name information is required for every Osterville MA 02655 10/16/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) A Approximate age of all components, date installed (if known)and source of information: installed -7/8/03-per info Were sewage odors detected,when arriving at the site? ❑ Yes ® No Building Sewer(locate on jite plan): Depth below grade: ;! feet Material of construction: ❑ cast iron ®40'1VC ❑ other(explain): ,i. Distance from private watec;supply well or suction line: ' feet Comments (on condition of joints, venting, evidence of leakage, etc.): - q Septic Tank(locate on site;plan): Depth below grade: 2 tanks # 1 -40 #2- 12" f feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) { If tank is metal, list age: { iyears Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: both 1500 gals. Sludge depth: is i' 2, I; t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts U Title 5 Official `Inspection Form f Subsurface Sewage Disposal System"Form - Not for Voluntary Assessments °M 268 Parker Road - Property Address a, Joan Lan enber Owner Owners Name information is l required for every Osterville t MA 02655 10/16/13 page. City/Town State Zip Code Date of Inspection s. D. System Information (cont.) Septic Tank(cont.). ;i , Distance from top of sludge;to bottom of outlet tee or baffle Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" i . Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions detel'm-ined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to out invert, evidence of leakage, etc.): The tees were present in both:tanks. No sign of Ieakage.Tank#1 inlet cover was 10" below. Tank# 2 steel cover was to grade." u C a , Grease Trap (locate on site;plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass 9 ❑ polyethylene El other(explain): N/a i�. Dimensions: Scum thickness w I ft 1 Distance from top of scum to top of outlet tee or baffle. Distance from bottom of scum"to bottom of outlet tee or baffle Date of last pumping: Date t5ins•,3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 k , f i t Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form Not for Voluntary Assessments 268 P`M arker Road Property Address Joan Lan enber Owner Owner's Name information is required for every Osterville f' MA 02655 page. City/Town State 10/16/13 Zip Code Date of Inspection D. System Informati®n' (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal',' ❑fiberglass ❑ polyethylene ❑ other(explain): N/a 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 pumps g contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 . i Commonwealth of Massachusetts " MOM Title 5 Official ' Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Parker Road Property Address Joan Langenber Owner Owners Name information is required for every Osterville MA 02655 10/16/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan); Depth of liquid level above outlet invert even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover;any evidence of leakage into or'out,of box, etc.): The D- box was normal. ' t I" Pump Chamber(locate on site plan): . Pumps in working order: Yes ❑ No' Alarms in working order. ® Yes El No* i Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): The pump was cycled and viorking. A steel cover was to grade. s. * If pumps or alarms are notl+inworking order, system is.a conditional pass. Soil Absorption System (SAS)(locate,on site plan, excavation not required): If SAS not located, explain why: , t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 12 of 17 q r j f Commonwealth of Massachusetts W Title 5 Official; Inspection For a Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 'GSM 268 Parker Road Property Address Owner Joan Lan enber I, information is Owners Na me e J required for every Osterville MA 02655 page. City/Town 10/16/13 State Zip Code Date of Inspection D. System Information (cont.) _ Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1 -42'x 13'x 2' ❑ leaching fields number, dimensions: overflow,cestspool number: El I 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.): There were no signs of failure. .i i Cesspools (cesspool must bepumped as part of inspection) (locate on site plan): •M.S Number and configuration N/a F Depth—top of liquid to inlet invert Depth of solids layer i. I' Depth of scum'layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 ih i Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts _ Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 268 Parker Road Property Address Joan Lan enber Owner information is Owner's Name required for every Osterville page. MA 02655 City/Town 4' 10/16/13 State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition bf soil, signs.of hydraulic failure, level of ponding, condition of vegetation, etc.): t;1 i� i 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.): N/a I , t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal "ystem Form Not for Voluntary 4 y Assessments ' M 268 Parker Road Property Address Joan Lan enber Owner Owner's Name 7, i information is required for every Osterville, MA 02655 page. Cityfrown ate Zi 10/16/13 Stp Code Date of Inspection D. System Informati®n (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Q I,A wk 13o as (APT: $ O 6 z1; 3 §0W3.6 $ ' 3 y �S �0•6 o 4 . • ,i . t5ins•3,'13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i I • Commonwealth of Massachusetts Title 5 Official" Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 268 Parker Road Property Address Joan Lanclenberg Owner Owner's Name information is required for every Osterville MA 02655 -------------- page. City/Town g 10/16/13 State Zi Code P Date of Inspection D. System Information'(cont.) Site Exam: ❑ Check Slope �, } ® Surface water ❑ Check cellar } ❑ Shallow wells is Estimated depth to high.ground water: 15' feet Please indicate all methods'used to determine the high ground water elevation: ❑ Obtained from system design plans on record 1 If checked, date'of design plan reviewed: Date ❑ Observed site abuttin( g property/observation hole within 150 feet of SAS) r ® Checked with local Board of Health-explain: " Using topo and"water contours maps ❑ Checked with 14al excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: t . You must describe how you'established the high ground water elevation: see above S i. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 s 7 Commonwealth of Massachusetts W Title 5 Official Inspection For Subsurface Sewage Disposal system Form Not for Voluntary Assessments 268 Parker Road i Property Address Joan Lan enber Owner Owner's Name information is • required for every Osterville MA page. Cit /Town 02655 10/16/Y 13 State Zi Code p Date of ♦ inspection E . Report Completeness Chec l'st® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D;f(System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file , f t5ins•3113 Title to 5Offclal Inspection Form.r Subsurface Sewage Disposal System•Page V of 17 i COMMONWEALTH OF MASSACJ.-J CJSErI7S r EXECUTh�1s OFFICE 01-, ENVIRONMENTAL An,'AIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM — NOT FOIt VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE, DISPOSAL SYSTEM FORM PART A CEItTIFICATJON Property Address: 0�. Owner's Name: — Owner's Address: Date of Inspection: Name of Inspector: (please print) 111e, �,� �.r� Company Name: Mailing Address: 'I rA Telephone Number: ' - uG�U� °` O J 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. 1-he 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 CNIR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation bN the Local Approving Authority Failst G t Inspector's Signature: s `�'` ��^�e� O` x, �, I)-ate: I� a� o � 701 s c^ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Iealth ors J DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow f 10,00Qv �-- gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional of i e of the C::) DEP._The original should be sent to the system owner and copies sent to the buyer, if applicable, and the _pproving authority. . Notes and Comments .***This report only describes conditions at the time of inspection and under the conditions of use at that time. "['his inspection does not address holy the s),stern will perform in the future under the same or different conditions of use. Tille 5 Inspeclioit Forttl 6/15/2000 page I t �y Page 2 of I 1 , OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) property Address: E tjg eaa�-R'n Owner: -- Date of Inspectivn: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section 1) A. System passes: V .1 have not found any information which indicates that an of the failure i 15.303 or in 31 C' Y criteria described in 310 CMR 0 NI Z 15.30 t exist. Any failure criteria not evaluated arc indicated below. Comments: I3. Sy�tcrn Crrndilionnlly I'nsses: One or more system components as described in the "Conditional bass"section need to be replaced or repaired.The system. upon completion of the replacement or repair, as approved by the Board of 1-Icaltli, will pass. Answer yes, no or not determined (Y,N,ND) in the for the following explain. statements. If"not dn ctcnincd"please 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 exfultration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by tine 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 duc"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 pipc(s)arc 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 pipes)are replaced obstruction is removed ND explain: I Page 3 J I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 01 Owner Date of Inspection: C. Further Evaluation is Required by the Board of licalth: Conditions exist which require further evaluation by the Board of Ilcalth in order to determine if the system is failing to protect public health, safety or the environment. L 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. Syslern +ill fail urilcss the Board of licaltli (and Public Water Supplier-, if any) determines that the system is functioning in a manner that protects the public health,safety and environment: _ The systern has a septic tank and soil absorption system(SAS)acid the SAS is within 106 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 front a private water supply well**. Method used to determine distance **This system passes if the well water analysis, performed at a DIP certified laboratory, for coliforni bacteria and volatile organic compounds indicates that the well is free from pollution from,thanfacility 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: 3 Page 4 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CEIZ'I'IFICA'I'ION (continue(l) Property Address: Owner: Date of Inspection: D. System Failtrc 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 i R Liquid depth in cesspool is less than G"below invert or available volurne 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 water supply. Ply y to a surface tt � An onion of a cesspool Y p spool or privy is within a Zone 1 of a public well. It U Any portion of a cesspool or privy is within 50 feet of a private water supply well. I► ►! Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply y w, pl well with no acceptable wat er to quality analysts. IThis system passe; if the well water analysis, performed at a DEI'certified laboratory, for coliforrn bacteria and volatile organic compounds indicates that the well is free front pollution front that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pprn, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma (5(Y 9escribed The system fails. 1 have determined that one or more of the above failure criteria exist as in 310 CMR 15.303 therefore th e system falls. The system owner should contact the Board of flcalth 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 (low 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) ycs 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—I WPA)or a trapped Zone II of a public water supply well If you have answered "yes"to any question in Section L- the systc►n 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 once of the Department. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM - NOT FOIZ VOLUNTAIZY ASSESSMENTS SUBSURFACE SEWAGE DISI'OSAL SYSTEM INSPECTION FORM PART It CHECKLIST Property Address: _ - Owner: _ Date of Inspection: Check if the following have been done. You ►rust indicate "yes"or"no" as to each of the following: Yes' No v Pumping information was provided by the owner, occupant, or Roard of I lealth V_/ Were anv of the system components pumped out in lire pre wious two weeks ? . Has the system received normal flows in the previous two week period ? lIave large volumes of water been introduced to the system recently or as part of this inspection? r Werc 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 ? V _ 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 ? V Was the facility owner(and occupants,if different front owner) provided with information on the proper maintenance of subsurface sewage disposal systerns'? The size and location of the Soil Absorption System (SAS)on the site has been detcrrrtincd based on: Y no 7 _ Existing information. For example, a plan at the Board ofHealth. _ 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)] 5 x. t ' y , Page 6 of I I OFFICIAL INSPECTION FORM — NOT FUR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properly Address: 6 Owner: Date of Inspection: RESIDENTIAL FLOW CONDITIONS Nutnbcr of bcdroouts(design):-5_ Numbcr of bedrooms (actual):__ DESIGN flow based on 310 CMIZ 15.203 (for example: 110 gpd x it of bedrooms); �Q Number of curTcnt residents:—6-t Does residence have a garbage grinder(yes or to : _ Is laundry on a separate scwagc system (yes or no : — [if yes separate inspection required) Laundry system inspected (yes or no): Seasonal use: (yes oro.. Water meter readings, if available(Iasi 2 years usage (gp(l)): -ENO S a13�{000 Sump pump Oor no): — ()U — I�6 t(LiG() Last date of occupancy: COMM ERCIAIANDUSTRIAL 'type of establishment: Design flow(based on 310 CMR 15.203): xl Basis of design flow(scats/persons/sgft,etc.): Grease trap I present (yes or no Industrial waste olcine taik present t (yes or no ): Non-sanitary waste discharged to the Title 5.system (yes or no):Watcr meter rgs, if -- Last date of occupancy/use: OThIER (describe): GENERAL INFORMATION Pumping Records Source of information:.-A&V-CA Was system pumped as part of the inspection (ye ort tc . If Yes vo lume pumped:d: gallons How wa s quantity m cd determined? Reason for pumping: TE OF SYSTf Aj Y�; —Septic tank,distribution box soil absorption, rp system —Single cesspool _Overflow ccss;)ool _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 corn Po nts, date installed(if known)and source of information: 11, rP 'fi �n A 1 Were scwagc odors detected when arriving at the site(yes or no : 6 OFFICIAL, INSPECTION FORM - NOT FOR VO1,I1N 1'Altl' ASSESSIlIEN'I'S SUBSURFACE SEWAGE DISPOSAI, SYSTF,M INSPUT-I•ION FORM - SYS"I•U M INFORMATION (c(nrtinucd) Property Address: (7^� Owner: -- Date of Inspection: BUILDING SENVI;It(locate on site plan) Depth below grade: r Materials of construction:_cast iron 40 PvC other(explain): Distance fiYmu private water supply well or suction line Comments(on condition ofjoints, venting, evidence of leakage, ctc): SBI'TIC'TANK: V(locatc on site plan) ).depth below grade: � � G % � Material of construction: ../concrete_metal fiberglass - -polycthvlcnc . —other(explain) - _. If tank is metal list age: __ Is age confirmed by a Certificate of Cotnpli;rnce (yes or no): (attach a copy of certificate) Dimensions: _ \r C Sludge depth: i- \ -- rr Distance from top of sludge to boitom of outlet tee or baffle: Scum thickness: Distance from toll of scut" to top of outlet tee or baffle: `( ^ (� 'p nt- `�t Distance from bottom of scuff" to bottom Of outlet tee or bafr I6 How were dimensions determined: Comments(on pumping recommendation., inlet and outlet tee or baffle condi(ion, structural integrity, liquid levels is r ated to outlet invert, evidence of.leakage, etc.): GREASE rRAI':_(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 bafrlc: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last puniping: —- C•oinrnents(on purnping rccornrncndations, inlet and outlet tee or bathe condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, ctc.): 7 Page 8 o1'I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY, ASSESSMENTS SUBSUILI"ACE SENVAGIE, DISPOSAL SYS'IT"M INSPI�,CTION TORT PART• C S�'STEI\I INI�OIZ�1A'I'ION (rt ntinuccl) Property Address: a(L Owner: ` Date of Inspection: TIGHT or- HOLDING 'TANK: (tank mist be pumped at little of inspcc(ion)(locatc on site plan) Depth below grade: Material ofconstruction: concrete rectal fiberglass pol`clh�rlcnc other(explaill): --- -- ---------------------- Dimensions: _ Capacity: --- -- — gallons Design Flow: —_ gallons/day Alarm present (yes or Ito): Alarm level: _ Alarm in working of Oyes or no): Date of last pumping: Ctattttttont5 (cnndilirnt o(nlor'rn (irtd Aunt nwitehon, etc.): DISTRIBUTION BOX: /(if present must be opcned)(locatc on site plan) Depth of liquid level above outlet Invert:_ Continents (note if box is level and distribution to outlets equal, any evidence of solids carl-Yover, any evidence of leakage into or out of box, etc.): .� . PUNIP CHAMBER: � (locate on site plan) Pumps ill working order( rc or no): Alarms in working order( e or no): Comrllerlts (note condition of pump chamber, condition of pumps and I)purtenances, etc.): 4fldxfv_1_R _ Y, Wage 9 of 1 1 OI I ICIAL INSPECTION ON FO RM NOT FOR OR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3L6% Owner: �_- Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): Z(locate on site plan,excavation not re(Iuired) If SAS not located explain why:- Type leaching pits, number. leaching chambers, number: leaching galleries, number: leaching trenches,number, length: , �e� X 3 oZ leaching fields, number, dimensions: overflow cesspool, number. — -- innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failurc, Icvcl of ponding, damp soil, condition of vegetation, etc.): 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 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: Dirnensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failurc, level of ponding, condition ofvcgctation,ctc.): -9 F Pagc 10 of I I OFFICIAL INSPECTION FORM — NOT FOIL VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSI T:M INSPECTION FORM PART C SYSTU,N1 INFOItMATION (rontitiucd) Property Address: Owner: Date of Inspection: O6 SKIsTCII OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including tics to at least two permanent reference landmarks or benchmarks. Locate all wells within too feet. I,o at whcrc public water supply enters the building. - � IC I a LA � _ a 0 a 0 r v 10 1"arc f I'o f 1 1 OFFICIAL INSPECTION FORM — NOT FOIL VOLUN'I'AIZ)' ASSESSMI,N,rs SUBSURFACE SEWAGE DISPOSAL. SYSTFIN1 INSPECTION FORM PART C SYSTEM INII(71ZN,IA'I'ION (contiiriiecl) Property Address: 1 6? 1 Q)oj&on � ���lJn nrs4 p Q Owner: Date of Inspection: SITE, EXAM Slope Surface water Check cellar Shallow wells Estirnatcd depth to ground water 115 feet Please indicate (check)all methods used to determine the high ground water elevation: ►� Obtained from system design plans on record - l f checked, date of design.plan reviewed: y 03 Observed site (abutting property/observation hole within 1.50 feet of SAS) Checked with local Board of Health-explain:_Checked with local excavators, installers- (attach docum_entation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 FMRYECEI.VE® CENTERVILLE-OSTERVILLE-MARSTONS MILLS FIRE DISTRICT 1 5 2003 1875 ROUTE 28 TOWN OF BARNSTABLE CENTERVILLE, MA 02632 HEALTH DEPT. (508) 790-2380/FAX#(508) 790-2385 OILIHAZARDOUS MATERIAL RELEASE FORM F.A.# 034 LOCATION: ADDRESS OF RELEASE. 268 Parker Road Osterville MA 02655 DATE OF RELEASE: 5/9/03 PRODUCT RELEASED: #2 Fuel_Oil ESTIMATED QUANTITY: Unknown CORRECTIVE ACTION TAKEN BY RESPONSIBLE PARTY: Notification NOTIFICATIONS. FIRE DEPARTMENT. ' ES(X) NO( ) DATE: 09 09/03 TIME:__I145O NATIONAL RESPONSE CENTER YES( ) NOV4 DATE: TIME:_________ DEPT. OF ENVIRONMENTAL PROTECTION YES" NO DATE: 2/05 OIL SPILL COORDINATOR: YES( ) NOM DATE. TIME: TOWN BOARD OF HEALTH. YES(X4 NO( ) DATE_05%09/O IME: 10 15 TOWN HARBORMASTER: YES( ) NOVA DATE: TIME: OTHER AGENCIES: ®----- COMMENTS.- On location w/Enviro Safe Corn at above stated ad ess Envy ro-Safe remova t nk frnm ai a fmind 1 :11rir,o PY[ av�ti n„ C Z A 0341 ein 9 aiar�G� -�arant to ex�av ton ro Nn n}�ri rn,a ci one nfkleaking ver ound within tank_ fill aix(Fil SS gallon rlr S Jina},lo o-Xhark & a that tank Wa R,�•_ rpmn�:od frnm ^4 aX[`^��^ti nr, of aroa rnnt 'm,orl ftpr rc 1 g stable $narrl of Aoa th nnynr.�,eMi,Q,ran, i 1 on ci to n� T CAip�] } .r nrmar for � REPORTED BY. u DATE:=5113103 Martin MacNeely, FPO WHITE COPY-FIRE DEPARTMENT YELLOW COPY-D.E.P. PINK COPY-BOARD OF HEALTH : 4v]M FORM#58 ' r` f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYST ����® PART A CERTIFICATION JUL 2 5 2002 Property Address: 268 Parker Road TOWN OF'BARNSTABLE Osterville, MA 02655 HEALTH DEPT. Owner's Name: Mary Jo McNamara Owner's Address: Same 4-- Date of Inspection: July 15, 2002 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map: 116 Osterville,MA 02655-0049 Parcel: 132 Telephone Number: (508) 862-9400 _ Lot: 1 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 Conditionally Passes , Needs F rther Evaluation by the Local Approving Authority Fails Inspector's Signature:\submian Date: July 17, 2002 The system inspector shcopy 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. Notes and Comments, ****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: 268 Parker Road Osterville, AM Owner: Mary Jo McNamara Date of Inspection: July 15, 2002 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 exfiitration 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 breakout 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 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 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY°ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A x CERTIFICATION-(continued) Property Address 268 Parker Road Osterville, MA Owner: Mary Jo McNamara Date of Inspection: July 15, 2002 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 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 orless than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. N' 3. Other: ` s 3 f Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 268 Parker Road Osterville, AM Owner: Mary Jo McNamara Date of Inspection: July 15, 2002 D. System Failure Criteria applicable to all systems: You must indicate either"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 T cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] No (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 System: 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. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 268 Parker Road Osterville, AM Owner: Mary Jo McNamara Date of Inspection: July 15, 2002 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: Yes No ✓ 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(3)(b)]. 5 Page 6 of. 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 268 Parker Road Osterville, MA Owner: Mary Jo McNamara Date of Inspection: July 15, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 'Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes r Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No. Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied • CO MMERCIAIJINDUSTRIAL 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:- Pumped in 2001 per owner Was system pumped as part of the inspection(yes or no): 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) (ifyes,,attach previous inspection records, if any). InnovativeJAlternative 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: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 268 Parker Road Osterville, AM Owner: Mary Jo McNamara Date of Inspection: July 15, 2002 ' BUILDING SEWER(locate on site plan) Depth below grade: Approx. 3' Materials of construction: _cast iron ✓ 40 PVC _other(explain): Distance from private water supply well or.suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: Approx. 2' Material of construction: ✓ 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: 1000 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (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.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 268 Parker Road Osterville, MA ` Owner: Mary Jo McNamara Date of Inspection: July 15, 2002 TIGHT or HOLDING TANK: None (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: None (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.): R PUMP CHAMBER: None (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, etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 268 Parker Road Osterville, MA Owner: Mary Jo McNamara Date of Inspection: July 15, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6'(1000 gaL) leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: ✓ overflow cesspool,number: 1 Innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation; etc.): The pit had approx. ]'of water on the bottom. The scum line was approx. 2'up from the bottom. The bottom to grade was approx. 9. The cover was approx:10"below grade The cesspool was dry. The cover was approx 20"below grade The bottom to grade was approx. 9. 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 or no): -- Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Original cesspool-abandoned. PRIVY:, None (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: 268 Parker Road Osterville, AM Owner: Mary Jo McNamara Date of Inspection: July 15, 2002 Map: 116 Parcel: 132 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 1 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. A►� aS ' A1 ' 1 - �a- 3a ;33 r 133- .► ac�k i ` �3- yF Qy- 3�1 ald o r 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C, SYSTEM INFORMATION (continued) Property Address: 268 Parker Road Osterville, AM Owner: Mary Jo McNamara Date of Inspection: July 15, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25°+1- feet 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: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain:' You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately 9. Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a'warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. i Il eo � DATE: _12/3/96 rIx ll PROPERTY ADDRESS: 268 parker Road , Osterville,Mass . � E 02655 DEC 6 1�' r On the above date, I Inspected the septic system at the above address. This system consists of the following: i. 1 . T-1000 gallon septic tank. 2. 2-61x6l Block cesspools. 3. 1-1000 gallon precast leaching pit. Based bn my Ingroection, I certify the following conditions: 1 . This is a split system. 2. Sewage end is a .title five septic system. • 3. The grey water end is a sew ge system. 4. The system is in proper wo3ing order at the present time. SIGNATURr,: Name:-J. P .Macomber Jr... i Company; J. P_MacoMber & Son-_Inc . Address:, -66------ ------ __Centerville , Mass__02632 Phone:---S0. _7_7.5L_333a------- • 1 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY CPH P. MACOMBER & SON, INC. Tanks-C�sspoolrLeschf leIds Pumped & Installed Town Sewer Connections x 66' Centerville, MA 02632-0066 775-3338 775-6412 Ul Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of environmental Protection Trudy Cox* &.u.ury David B. Struhs U.Gow: cartvnhawrrr a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 268 Parker Road Osterville,Mass Address of Owner. Date of Inspection:12/2/96 (If different) Name of 1n,pectcr.Joseph P.Macomber Jr. Company Name,Addreas and Telephone Number. J.P.Macomber & Son Inc.Box 66 Centerville,Mass. 02632 508-775-3338 CERTIFICATI0N STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Conditionally Pasaes -_ Needs Further Evaluation By the Local Approving Authority _ Fails lmspertoes Signat �Z /J ��� Date: The System Inspecto s submit a copy,of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 MA or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner;md copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: Al SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CUR 15.303. Any failure criteria not evaluated are indicated below. BJ SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes inspection. Indicate yes, ao,or not determined(Y, N,or ND). Describe basis of determination in all instances. If'not determined", explain why not) /Ud The septic tank is metal, craAad, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is immiin at. Tha system will pass inspection if the existing septic tank is replaced with a conforming septic tank sa approved by tL. Board of Health. (revised 11/03/95) l One Winter Street • Boston,Massachusetts 02108 • FAX(617) 55&1049 • Telephone (617) 292.55W �� Primed on Recycled Pips i r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontlnued) PropertyAddresu 268 Parker Road Osterville ,Mass . Owner. Jeanne R. Kerr Date o1 Inspeotlon: 12/2/9 6 B) SYSTEM CONDITIONALLY PASSES(continued) /1_QJ8 Sewage backup or breakout or ho static water level observed in the distribution boa is due to broken or obstructed pipe(.) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Hsaltlt): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced Ths system Teguired pumper more than four times a year due to broken or obstructed pipe(s). The system Will pass inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:- Conditions alst which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WALL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 4/0 Cesspool or privy is within 60 feet of a surface water DCesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh R) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 60 feet of a private water supply wal The system has a septic tank and soil absorption system and is less than 100 feet but 60 feet or more from a private water supply wall,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the wall U fees from pollution from that facility and the presence of ammonia nitrogen Lad nitrate nitrogen is equal to or less than 6 ppm. 9) OTHEji / �/ • S �✓/ � I OG� G,eS� OGIc, �/�d(7 l�• Dkltey 001eC4 C 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Pr•opertyAddre,v 268 Parker Road Osterville,Mass . Owner. Jeanne R. Kerr Date of Ia•pectlon:1 2/2/96 D) SYSTEM FAILS: • _AA I have determined that the system violate$on•or more of the following failure criteria as defined in 310 CMR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. - Backup of"wage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface cf the ground or surface waters due to an overloaded or clogged SAS or cesspool. /IAV/Q, Static liquid level in thel,'4,tribution box above outlet invert due to an overloaded or clogged SAS or cesspool. /4D Liquid depth in ceaapool is less than 6"below invert or available volume is less than W day flow. L, ,fLQ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe($). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Al Any portion of a cesspool or privy is within 60 feet of a private water supply well. dj Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: �Q The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: /0 the system is within 400 feet of a surface drinking water supply AL1r 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 U of a public water supply well) The owner or operator of any such system shall bring the system and facility Into full compliance with the groundwater treatment program requirements of 314 CMR 6.00 and 6.00. Please consult the local regional office of the Department for Auther information.. v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Addrem Jeanne R. Kerr Owner. 268 Parker Road Osterville,Mass . Date of Inspection:12/2/9 6 • Check if the following have been done: , 4/pumping information was requested of the owner,occupant,and Board of Health. �ons of the system components have been pumped for at least two weeks and the system has been receiving during that period. Large volumes of water have not been introduced into the systemn of normal flow sates recently or as Part of this iaspedion. Z-'s built plans have been obtained and examined. Note it they are not available with N/A. The facility or dwelling was inspected for aigns of sewage back-up. - The system does not receive non-sanitary or industrial waste flow , The site was inspected for signs of breakout. Ail.system componsnb„ icludfng the Soil Absorption System, have been located on the site. „ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tow, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. The site and location of the Soil Absorption System on the site has been determined based on existing information or a rcaianated by non-intrusive methods. A4. The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal system. (revised 11/03/95) 4 SUDSUIWACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddre•ar 268 Parker Road Osterville,Mass . Owner. Jeanne R. Kerr Date of lnspoutivt.: 1 2/2/96 FLOW CONDITIONS RES 1 D ENTIAL- Design Dow: d ¢aIIoas Re^MY Number of bedrwmi:�; Number of aunat rvsidents:X GarbaEp Mader Qrw or no): AV Lundry connected to rysum (yw or no): Seasocal use (yes or no):-�� Waur meur readings, if available: 1�9 or' . /L)71 Oeb alg4ld4) ' X967W6gJZ.,L Q Y �to�v�k y .� ,� g,o.t1 a►o S- �3�i C.�1,owS Be,ri l.Ast dau of occupancy:AOL% COMMERCIAL/INDUSTRIAL- Type of utablishment: A)6 Da•b^a Dow:_Adjj_gaUons/day Grace trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no)_-y4 Non•saaiu,ry wasto discbargvd to the Title 5 system: tyes or no)—A)-4 Water meter read.ia,;s, if available: AXE A _ Lest Cats of o=pa cy:_/AA OTHER (Describe) 1 Len date of occupancy: _ GENERAL INFORMATION PUMPING RECORDS and souru of(nforcratiow System pumped u pan of inspection Vee or no)Ive) If yes, volume pumped: A i9 ucu Reason for pumping: NISI TYPE SYSTEM 1/ &PLic absorption s)Ytem Overpow ce•:spwl J 6d&-#1pW/d/'ec 4�1 /,)r Privy Shared ryvum (yes or no) (if yew, attach previous inspection rewrds, if any) Other (e=plr.in) 7 PROXIMATE AGE of J components date u.ju.Wu.( (if kr own) and ro of information: A,4VG2*�;%5 Sowave odor decsvcxl Wti� �. .t r ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. • • SYSTEM INFORMATION (continued) Property Address: 268 Parker Road Osterville ,Mass . Owner: Jeanne R. Kerr Date of Inspection: 1 2/2/96 SEPTIC TANK:1040 OX2( i we e (locate on site plan) Depth below grade:__ Material of construction: concrete _metal _FRP_other(explain) Dimensions:—?' '� 1 Sludge depth: e• Distance from tog of sludge to bottom of outlet tee or baffle: Scum thickness:/X'ff�e— Distance from top of scum to top of outlet tee or baffle:,7�I� Distance from bottom of scum to bottom of outlet tee or baffle.,liQrz— Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle,. depth of liquid level in relation to outlet invert, structural rity, evidence of leakage, etc.) Pump tank every 2—� years,jn]�et outlet teQS ara tt GREASE TRAP.A/Mt (locate on site pian) Depth below grade:Nlfl- Material of construr-tionA//i:oncrete _metal _FRP _other(explain) z N/4 - Dimensions; Scum thickness:2 Distance from top wi scum to top of outlet tee or bah•le:_40 Distance from bottom nt srum in honnm o) outlet IPe or baffle_/UA Comments: (recommendation for pumping, condi—ri of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.i2rease trap is not present. s (revised 0/15/95) 6 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertyAddrese: 268 Parker Road Osterville ,Mass . OWaer. Jeanne R. Kerr Date of Inspootlon: 12/2/9 6 TIGHT OR HOLDING TANX-"4l5 (locate on site plan) • Depth below 1pade:.—VA Matarial of construction:04conerate_metal_FRP—other(explain) - A1A A)4 Diman,cions: A)A Capacity: AA ¢allons Design 11ow: &j calloWday Alarm level: el%4 Comments: (ooaditiou of inlet tee, n T Lleff and¢oa a{, l g nor t o Ing` an ```Is not present. DISTRIBUTION BOX:_LWGG. (locate on site plan) Depth of liquid level above outlet invert: NA Comments: (not`if is el and iustr10 lox LO c riotr,pre s e2f 1 . inCO or out of boa, etc.) PUMP CRAMBER:&,d/e— (locate on site plan) Pumps in working ordar.(yes or no) Comments: (note condition of pump chamber,condition of pumps Lad appurtaaanoes, etc.) P11mn nhamhar is not pragant I (revised 11/03/95) 7 .:. „r �• ...; THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I MF- I - - DATA SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :r PART C r SYSTEM INFORMATION(oonUnued) =6-& Parker Road Osterville ,Mass . ":eanne R. Kerr 2/96 .ids W�7�•�i.. excavation not required,but may be apprcaimated by non-intrusive methods) • uplabu tsasb�s:� number:_ '''�.aumb•r• ''"''aumber,leagth: pumb•r,dimensions: Y.+rti II1imbYT:,� :. of soil,,sigiu of hydraulic failures level of ponce,condition of vegetatlo etc.) o fine sand•No si ns of h draulic faillure • o si ns o 3nA n nve e ation is norms . No repairs needed at the invert: r !it atnust be pumped as part of iaspection) of soil,sips of lydraulic failure,kvel of n=dinly oondition of etc.) rbo fine sand•No si ns of h draulic- failure •No signs of p NA NA of soil,sigas of hydraulic failure, level of ponding,condition of vegetatlon,itc.) y is not present el .;> a: � fit. f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION •FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L:SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' Centerville Osterville Marstons Mills Water Company 428-6691 VV)0% 9x'► d7 —46 i DEPTH TO GROUNDWATER 121 + depth to groundwater r+pth.od of determingign lnstalled:.:t-aM' & 'per..-in Permit- #375 No water encountered a e un -san_• to . .. e.;,san -: an on i e at trig .13arris table oar f� LOCATION SEW G E PERMIT N0. _ VILLAGE INSTALLER'S NAME & ADDRESS do K B U PL D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 03 �O '? o V .,0 .43 p 41 II j. 0 3C 20 80 90 r* 09e . Nc. r TO 6c- .39 ac- C- 16 111 .60 I As tr ut c br-- "E" 0%0 \ �� ., 76 �j 94 0,bl1 Kct 11 70 1 69 NC 5C PS, 72 .00. 7��, — THE C®N'�,\J NWEAT�TH OF MAQSACHU '� l� ,►. . , ,ram ' �_t fi.�FF E '�:' E IT 1N` . , MV THA J Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLIE 5 SYSTEM INSPECTOR as provided in 310 CMR 15. 340 and Section 13 of Chapter 21A of 1:he General Laws. Issued by The Department of Environmental Protector- Junc S, 1995 - —- acting Director of the ion of Water Pollution o i •rrnr+•-ntr�r•.•n-+rnram•nsnrs-nnrsnrr. r-m��►1�s�+•.rnm mrnZ++a�+Rao urn .rmrr-�r—r-...--.r-..•` TOWN OF Barnstable WARD OF HEALTH + \ I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I `� F.^•TR^T•'.••. t-T.fIT.^..:rn�S r.n•rtrnr7TlC'TTran�tTt:r't+"1uf+e7anrnfTIRR.C.IIR/RRTI.a'tv'fer� Rm ..:rrr•1-•ter�..A -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 268 Parker Road Osterville,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # 116-132 OWNER' s NAME Jeanne R. Kerr PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME J.P.Macomber & Son Inc. COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 3338 FAX ( 508 � 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of .-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: CXXXXXXXXxXSys tern PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or Lhe environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluAted are as stated in the FAILURE CRITERIA section of this form , System FAILED* The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date 12/3/96 <> One copy of this c t.ification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALV(. * If the inspection FAILED, the owner or",o^ orator shall u p pgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 15 . 305 . partd .doc LOCATION VILLAGE ��. y/.r.��, yYl/ S ASSESSOR'S MAP & LOT NAME&PHONE NO. rf SEPTIC TANK CAPACITY LEACHING FACILITY: (type) /�� CS /Z .T(size) NO.OF BEDROOMS BUILDER Olt OWNED-1'�llJ/1� PERMITDATE: ��—�' COMPLIANCE DATE: 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) V Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet o leaching ac' 'ty) _ Feet Furnished by 9x� d� ' l0 � qi ,fit i sr . j TOWN OF BARNSTABLE LOCATION g(OS"" PgA* _ 98 SEWAGE # VII...LAGE D CTerV, � ASSESSOR'S MAP & LOT INSTALLER'S NAME& PHONE NO. SEPTIC TANK CAPACITY f C/lTh SA ' LEACHING FACILITY: (type) CC$$00-1 R� (size) 60k(,P' 1 M 64 NO. OF BEDROOMS 3 _ j3UILDER OR OWNER rAAE C7 (" MArA PERMITDATE: 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) 1 Feet Furnished by ��nSp&U2 iyn �OtG+ 1 Aa-3a Qa- as a C,y- 3S' e�s�P�I ces�pwl a -- //��� vv TOWN OF BARNSTABLE LO :ATION ow-1y�/peo� /Cy * � •'��,G VILLAGE �S/ y/� SS ASSESSOR'S MAP& LOT NAME&PHONE NO. l SEPTIC TANK CAPACITY AOD LEACHING FACII.TTY: (type) /�.�'f{ /���5 /Z l (sze) �� — NO OF BEDROOMS TsLUDER OR OWNER �i�Jl1/1s� PERMITDATE: COMPLIANCE DATE: 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) V Feet. Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching ac';ty) Feet Furnished by } ep' �7 � r 47 tolls — cQ e Gp i TOWN OF BARNSTABLE f• 'A7'lON •2(.P7 Parl(W I SEWAGE # J V ; >; GE ©S'�.r✓i[fie, 1, f ASSESSOR'S MAP & LOT — 32 y INSTALLER'S NAME&PHONE NO. �1 i[It kK3 U� O • 3(P2-6300 SEPTIC TANK CAPACITY LEACHING FACILM': (hype)(°) 00 a6S• Lk++6t a (size) 50044(, .'NO. OF BEDROOMS BUILDER OR OWNER LJtn "PERMITDATE: `1 03 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 A q6l © ,soo 5f. A 2 `{'7 0 ` A 3 so' A 5 c6- A G q6' oq Aq VZr 61 33 �- ' �[2 ►3z 31' c 93 43. 7 Bq /36 °7o• TOWN OF BARNSTABLE LOCATION 2�$ P � I� SEWAGE # "M3�1y 2 VILLAGE S'hr V ASSESSOR'S MAP &LOT U- 32 INSTALLER'S NAME&PHONE NO. yy i lli 6�w�S �D�� 3(a—(°30c) SEPTIC TANK CAPACITY LEACHING FACILITY: (type- ° l Lkamb '3 (sine) O 4 NO.OF BEDROOMS . BUILDER OR OWNER t PERMIT DATE: ffO:33 COMPLIANCE DATE: (TIO3 I Separation Distance Between the: l Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) i Furnished by a, VIL 77'- z. No. o 0 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes A� PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Migoml *pe;tem Conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) .Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 268 Parker Road 508-778-7127 Assessor'sMap/Parcel Osterville, MA Sheila & Glenn Tobin 38 Evelyn Circle, Centerville MA Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.5 0 8—7 7 5—0 7 3 5 Tim Williams 508-362-6300 Weller & Associates 86 Willow St Yarmouth Port 1645 Falmouth Road, Centerville, M Type of Building: Dwelling No.of Bedrooms Lot Size a sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow S S ® gallons per day. Calculated daily flow Co gallons. Plan Date 2,11 q In -? Number of sheets 1 Revision Date Title n, i M� Ce;(A-.iACnt�_- 9 LAit..) Size of Septic Tank 15 ocn Type of S.A.S. ,cues Q.A" nR_tC W0-.0 Description of Soil a P Nature of Repairs or Alterations(Answer when applicable) Date last inspected: k�_/P h)t to S -?S-TS rr7 Agreement: The undersigned agrees to ensure the construction and aintenance of the afore described qn-site sewage disposal system in accordance with the provisions of TitleaoEEF'rentalCodde and not to place the system in operation until a Certifi- cate of Compliance has been issued b th Signed Date Application Approved by � -� Date 7 u Application Disapproved for the following reasons Permit No. 2.603 —1 91, Date Issued d ---.._..------------------.-- ._�------- No. ` r �r ,•; ` ' Fee O V THE.COMMONWEALTH OF MASSACHUSETTS.` Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF-BAR NSTABLES MASSACHUSETTS 3ppricatioU for �Digoogal *patent CoUMruction 30ermit Application for a Permit to Construct( , )Repair( )Upgrade( )Abandon( ) 7jecomplete System 0`Individual Components Location Address or Lot No. '`'' Owner's Name,Address and Tel.No, 268 Parker Road Sheila & Glenn Tobin —7 7 8—712 7 Assessor'sMap/Parcel Osterville, MA n38 Evelyn Circle, Centerville,MA i Installer's Name,Address,anfiel.No. d ° Designer's Name,Address and Tel.No. 5 0 8—7 7 5—0 7 3 5 Tim Williams 508-362-6300 Weller & Associates , s . 86 Willow St Yarmouth Port MA . ,, ! 1645 ',Falmouth Road, Centerville, M Type of Building: `�.'," ,N`Dwelling No.of Bedrooms 5 L'Aize .5S AG sq.ft. Garbage Grinder( ) ' 'Other Type of Building No!of Persons Showers( Cafeteria( ) Other Fixtures Design Flow 5 5 O \ gallons per diV.,Calculated daily flow gallons. Plan Date /1 4 M Number of sheets. -1 Revision Date l Title f 'c Size of Septic Tank 1 S co© ^'° "(' Type of S A S e�S o o', MP A" Mi►2 tr_W E u Description of Soil sF_Es P L—,61�1 •i`, � '-_- �'" t � Nature of Repairs or Alterations(Answer when applicable) Date last inspected: 1L,/ /Pa — ►o t✓L s -,Ts M Agreement: ' The undersigned agrees to ensure the construction and aintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 00 - E 'r . fnental Code and not fo,platC the system_ ropera ion until a Certifi- cate of Compliance has been issued by this Boar / Signed '1. .. "., Date 171 03 . Application Approved by Date 7 u Application Disapproved for the following reasons t- _ Permit No. or)o� ` 1�I �f�s a Date Issued 4 d .•°� i , " y THE COMMONWEALTH OF MASSACHUSETTS - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by m S c►3 1 L ).L h 1 V at has been constructed in accordance with the provi ions of Title 5 and the for Disposal System Construction Permit No. 20o 3 —I V2 dated y 3 Installer Designer The issuance of t�'s permit shall not be construed as a guarantee that the syste f do e gn . Date 03 Inspector s _. No. Fee 10d THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ie; ogaY 6pgtem CoU5tructiott permit Permission is hereby granted to C nstru�( )Re air( )Upgrade( )Abandon( ) System located at N and as described in the above Application for Disposal System Construction Permit.,Thel applicant recognizes his/her duty to comply with Title 5 and the.folloing local provisions or special conditions. Ll IV/ Provided:Construction pust be completed within three years of the date of this it. Date:_ 1_'qvi� ''' ^""`_- Approved by I"J- 4Ae �� . a � ��.�+ 'C yair•� a .i 4r t'�� I k .. w.t w r •t, _y z - 1 r t � 4k- x � r: r y �/ }., � _ - �„e�. .�.,�_ . ...,�- iyl::v.. ' ;i.i / � � � ,h PI 1 NXI �•� ".I��\ Qua (� _ r S2 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1.toI >- ....-----OF.....� k)u& )s.................................. Apli iratintt -fur Uiiipuiitt1 urko (butt r�trtt�tt Prtltit Application is hereby'made for a Permit to Construct ( ) or Repair ( k<an Individual Sewage Disposal System at --- -•--• ' - -1------------�...7.. ---------•-----------------------------_--_-----------•-.---------------------------------- d` j Location-Address or Lot No. M'- C; ----- ... r �i .....................•-----------•--Address Installer Address Q Type of Building Size Lot............................Sq. feet Dwell 1-1 p, Other—Type Typeoof BB ldt gms_________________________ No. of . Expansion Attic ( )Showers (Gajbage GrinderCafeteria ( ) Q' Other fixtures .........................:. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity---.---_---gallons Length................ Width.__-_---..-..... Diameter---------.------ Depth.__._--__.--:-- x Disposal Trench—No- ____________________ Width.................... Total Length_-__-__-____----__- Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date------------------------------------._.. a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water..----.-_--____._.-___- f= Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water a - water--. -.---_-_--_-._-____. ....... ----------.....-----------------------•----------------. ---------------------- ------- D s...•--..• ---------------- Description o o --------_ � �C V U Na ure of Repairs or,Alteratio saver when,applicable._._ M_ ."� __._....Ac__4�� l ?/ :/Q-?. _._.._. _._.. Agreement: The,undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article aI of the.State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bimmissued by the Ward o h lth. a . ' � !"� ' Date Application Approved By---- � . w /// 1_77----- - Application Disapproved for the following reasons--------------------------•---.....------•-----..........--------............................................... ---------•-------------------------------•--------------------------------------------------....----•------•---------------------------------------------------------------..---------------- Date Permit No..... d;7....................` ----.... Issued.• � �---------------------- Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I A , m / � LI DATA .e• .• 1. t 'ti. d _ NC77) .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH !�� .�............OF..... t. .f.f� Appliratioo -for Biquoottg Worko Tomitrortiou Vautit Application is hereby'made for a Permit to Construct ( ) or Repair (4-51"an Individual Sewage Disposal System at: , I �--V y r f Wit+ /A rK �! ---•- . •.....•-•-••-•----•-•---•--•---•••••••••••••-•----•----•--•--•-•-•----•-•--•...... ..........••••---••--•----•-------•••••••--•-----•-••-•--•--•-••••••---•-•-----•---•-....•••--... r f Location.Address or Lot No. ��•/ /l J, h Owner Address afig. i,.. ,-ram Installer Address UType of Building Size Lot----------------•-----_--•Sq. feet Dwelling—C/No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons_-_-__-..____---_--_-•--_- Showers ( ) — Cafeteria ( ) dOther fixtures ---------------------------•---------------._....... ---------------------------------------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow........................................-...gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter----------...... Depth--------....... x Disposal Trench—No..................... Width-_-----_--_--_-__- Total Length-.------_.--------_ Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet_-_--____-__-_--- Total leaching area..--..-_---.-_..sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY-------------------------------------------------------------------------- Date----------•-----------------•--------... Test Pit No. 1----------------minutes per inch Depth of "rest Pit_.---___-__-_----- Depth to ground water....-__---_-- _.---_- rZ'q Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.._.-_-_-_-..-----.... D Description of Soil---------- fr�.........__.._�....-__.._ .....�► c. x U ------------------------------------ -••-••-•--•-------•------•-•••-••••-•--•-----•-----•••---•••----•-........--•---------••-•-•-•-•--------••••---------------•••-------------•......--------•------- VW ----------------------- ------------------------------------------------------------------------------ ----------------- ---_-_----------------- ------------ ` ------------------------- Nature of Repairs or,Alterations—Answer when applicable.--_�-- ��_,F�f v r_'1� ry ` 1/j G r : '_ r a l //, v �1I� //✓ " 1f-Ir.�i17- e7 .f I.I tt� rI'-, f ---......--•-••----_ ----•-----------------------------•-•---••--•-•----------•-_----------------•- ---------------- Agreement: r The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beemissued by the board of health. F1111177 ,/ ) • �; I.J Afire-ram 1-A, f/ 1// 77 Si d_._ Application Approved B `l_ ........................ a-7Z Application Disapproved for the following reasons:................................................................................................................ .................................................................................................. -••-.......•-----------......_••••...........---.....--•---------•. •---------------------_--- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 r - ae f .......................... Tntif iratle of f.1,11mphanrr THIS IS TO`CERTIFY;gThat the Individual Sewage Disposal System constructed ( ) or Repaired (r✓-r by...................f............•f......-�............... Installer at................................! G? 1k,-- A , ! � 1r�� /c_�l� ---------••---•-----------••-•-•••-•..........--•--•--••-•.... has been installed in accordance with the provisions of : �f l� XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. ..../......J.7S7........ dated-...__,7__-./1_--- .7 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 7 r / . DATE_...��. .. Inspector 6-------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f /" Ir �. .........O F.......�`1/�;�- r.1,!/! �C(".No......................... FEE---"-.................. %npotittl ork boo #r�trtioit f rrmit jPermission is hereby granted-------..-------`=-'`^`=----------=�-•-_.---�'-.�✓.--�,••....---ft.-,.„-�----�---`-:::_-`=-------------------------------•---...--- to Construct ( ) or Repair ( ✓)an Individual.Sewage Disposal System atNo............... 'f ...................................... -------------- ------------------------------------------------- ............... Street as shown on the application for Disposal Works Construction Permit No.-..--_--._`_:-.--_-- Dated.......................................... ---------------------------------------- ----- .................................................J DATE...7.1. 7'/--------------------- _- Board of Health FORM 1255 HOSES & WARREN, INC.. PUBLISHERS ! m I f' SSIB TkYA1EV PECK W/ WJJ06JWY OK FIR DECKING -- — v Ir-------- ==-=t-----__--_-__-_--___-____-----'-_---_- N Q i j ! :'-v _�o _ �-e' _-> -s-s �;r-,'a yr �F-sd us = sa r• -�a—.:::✓r- -a'.' _v.. -asv _ 1 - �.—_-_-'i--'_'.-.— ' ne 76Cc�_x✓�,e _ sF oa cc or mau awe t '. " •I ! I +— .�,', , ; •g., e ' ,� � G'x xv:-536n1x yr- I-�T :j T z I x soax b e ji I -•—.A—_ ..- ____ Ti Imo/. 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TOP ra�vATIaJ ODvERS TD wtrnN mw Ppa LENGTH DYER 1314"-1 V2 PoLftE TO x SET LEVM WANDSTOW DATE: SEPTEMDER V,2002 DAI LY FLOW: (5)B a C- EDROOMS x I PD=550 C-PD �, 3S. i' M MNMIW 6RADC rat MN. r TEST 15Y: M.O'LOU6HLI N,CSE SEPTL TANK: 550 OPP x2001=1 190 611D �. rN6M eftA x WITNESS: D.STANTON,¢ARNSTAPLE 150H USE: 000 GALLON PRECAST SEPT G TANK s o PERG RATE: <2 MIN/IN LEAGHWv FACLIrY: USE: (�)500 COAL.PRECAST DRYWELLS LI NED W IrH 4'OF w,� " TOP a B..3z.Z 35A all DOUDLE WASHED STONE ON 51 DES&ENDS -- e- �.5 5,pn r�AL vRYwe�Ls Ap Z�3 CAPACITY: corraM A zy.s 1vYR3/>3 33.7 SIDEWALL: //,0 x 2 x 0.74 = /�i 2.6 ,.. g, DIST. bO�c 35481 16,, BOTTOM: IV x Ye x 0.7�4 = 'S�os!o ram: d StFARATION 6�0 6►�LLON Pw LOAMY 5AND TOTAL: evnc r* 32.3 10 5/a 32 4 i" 51Y3fi " D+►�.� pDTfOM or TE51` 110.E A 9.L`V. Z4.5 Q PRUT I LE NOT TO s6Al_E _ s*V COVER TO WITHIN COVERS"1"O WITHIN A" OF FINISHED 6RADE. 6.. OF FINISHED GRAPE. COVER CAST PUMP sPEO F I OAT I ONE 2A.5 „ epARA6E SLAB @ raGt1 V USE: MYERS SRIM�4 PUMP (OR EQL&) ELEv.".�t ` ' WITH VISIVLE & AUPIMLE ALARM NO WATER ENOOUNTEREP �� '� ` • ` INSTALL 115V SINC-A-E PHASE LINE TO PUMP .•� `.. « Pvfl INSTALL .SEPARATE LINE FOR ALARM a `�'► 'b i'T' w�ae NOTE: ELECTRICAL PERMIT REG�UIRED FOR PUMP VIM '>O.`aD DISI". BOX INSTALL 6M pArP11'. 3 ' 9.50 iNDurterree g.5 U P � 6.. STONE BASE I500 6At LAN /-5•00 OA1 -ON SEPTIC TANK PIMP GHAMPER 6.. �-ONE BASE i 2�, PLMP ELEVATIONS GENERAL. NOTES MOM WATER ALARM: 0" PLWON: 7 s \ l G ONT'RACTOR TO X RESPONS15LE FOR THE L06AT19NOF ALL UrUrrES, ABOVE AN7"EROROUND,PRIOR TO ANY ECAVATON OR 6ONSTRLGT49N. 2. SEPTL SYSTEM TO GE NSTALLED N COMPLIAGE W IrH 3 ,I iv U=>tv fOR Pr�,'OPER i Y i_NE PETERMNAT19N r Z �4. ALL DST AREAS URDED REA TO M LOAMED AND SEEDED 5. CONTRACTOR TO PROVDE 7. 4 HOUR NOTCE FOR ANY RECZUREP NSPEGTOW _...� s 5. 54 1 t o � z n4 I p0 p 1 id SI10 TE �EWAOE PLAN t O 1 LoGAr1oN: 268 PARKER RP. OSTERVILLE, MA t i 32 PREPARED FoR: C�L.EN N & Sf IE I LA 70f5 I N 1 I SCALE: DRAWN 15Y: 1 .1 35.2 TMW 1 JOB NLMDER: DATE: 5t1EEr: TEVEN ,,, OZ-�05 OZ-I�-2003 SP-I RUM :cis clvi,_ No. 32L.: WELLER & A�3�300 I A r 6 <.<a T S��NAL I(oh5 FALmoff 1 RD �► 5UITE .46 GENTERVILLE, MA OUn S dd 2- 2o. -v 3 TEL.: (508) M--07: N FAX: (508) ?75-075q PROFESSIONAL ENGINEERS & LAND SURVEYORS