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Home My WebLink About0585 PARKER ROAD - Health 585 Parker Road Osterville A = 114 - 064 �A r No.. Fs a... ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALS �. -- .OF.............,,. ..... +.- ...... . r , vvftrtttinn for DhiVo l Workii Tonmrurti u Prrntit Application is hereby made for a Per 't to Construct ( 4<0r Repair ( ) an Individual Sewage Disposal S st 4.T?! ----11"11-1111av""".- .0....h� , tion-Addres or W W ner � � d..--••----• . -��/ ----• --• ........... ... . ...... .........................•--- Installer Address Type of Building ,h Size Lot... C... .Sq. feet U Dwelling—No. of Bedrooms_________ __________________________Expansion Attic �) Garbage Grinder (4-�— aOther—Type of Building ----------------------_--- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------• __ g -___-____-_ gallons per person per day. Total daily flow-------------- � .__..._......gallons. W Desi n Flow________.___ _.._._.__ -t11 P WSeptic Tank—Liquid capacityl-40t1---gallons Length................ Width................ Diameter................ Depth.-.----.__.----- x Disposal Trench—No..................... Width...............----- Total Length.................... Total leaching area..............------sq. ft. Seepage Pit No-------c ------- Diameter.................... Depth below 'nlet... .....___.._._.. Total leaching area-_--...._-_-----sq. ft. z Other Distribution box ( ) Dosing tank ( ) �� - ion — 2. - 2..-0 - 74 aPercolation Test Results Performed bY------- ------•-----...._.....------------------------------. -_.. Date.......................... ------------ ,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-------__--__.--.-..._. �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ a ------------------------- -- -- ------ - ------------------- ----•-•---;---------------------------------------------------------------------- ODescription of Soil--------------------- -- ......................� -- ------- x..................................................---------------------_- --- U -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W V Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ -------------------------------------------- --------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b bo f he h. Signed---- -- . . - ------ .................... el D.... .. Application Approved BY - - I- 00 - Date Application Disapproved for the following reasons:-------------------------------•--------- .................................................................. -----------------------••--•-•------------------------------------------.--------------•---•------------•--•--•----•---------------•----------------------_---.-----------------------------------.----- Date PermitNo......................................................... Issued........................................................ Date a........................-......................................... TH.E COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH - / �1 ....................OF_........ ... .... ....,. .............. ................ �rrtifipte of TomVlittnrr THI.��S T C TIF Y, That the Individual Sewage Disposal System�onstr cted ( ) or Repaired ( ) oo �.�_ ... Y - ................ = / , ---- - -� -A- -- I-e� at ' - t� . -- - ------------------•-------- ---•--------------- has been installed in accordance with the provisions of Arf e X of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. __.. ---------------- dated..._ ._ _.. -"__7_l��_.._... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector------------------------------- .................................................... r 4 No......................... r Fizic ...'...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... .__ ... ............OF...................................................................................... Appliratinn -fur Uhipuiial Works Tonstrurtion Vrrniit .Application is hereby made for a Permit to Construct ( 4'j"or Repair ( ) an Individual Sewage Disposal Sys .......................................... ----....... ............... •- -------•-•---- ion•Addres or o -_ -��._..._ � � - - --------- j J caner Add f!s /�rj�/l � /� -----•-•-••-- y a / f{{ C-/ffcf C 1� C ) � // _�_- ----•--------------••__--•--•--- ' ................... -•--•-••---••....t Installer Address '` ...S feet U Type of Building � Size Lot....r„a�..._.... q. Dwelling—No. of Bedrooms........... . ..___-_--_-_-___.--__-_--Expansion Attic Garbage Grinder Q`-.1 Other—Type of Building ____________________________ No. of persons---_•---.__•-____-_-__-___- Showers ( ) — Cafeteria ( ) dOther fixtures --------- ------------------------------------------------------------------------------------------------------------------------------------------- W Design Flow______________ ------------------------------gallons per person per day. Total daily flow............................................gallons. P4 Septic Tank—Liquid capacity] __gallons Length---------------- Width................ Diameter_---.......-_-__ Depth---..-----.----- xDisposal 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 "Pest Pit----------------_--- Depth to ground water........................ f1 Test Pit No. 2................minutes per inch Depth of Test Pit._-______._____-____ Depth to ground water_------------ ........ RBI .._......--•-------------------- --------•-----•--••-•--•----•-----------------•----------------•----•----------------•------------------------------•--- ODescription of Soil--------- --------------�--_.�:....------�.....` ........----/--`-....__...........-----•----.........................--.------------------- x : W .w U Nature of Repairs or Alterations—Answer when applicable----------------------------____.-.___-_..-._--_.-..__-_._-_--__---_-----.----_--...._-_.-... ----------------------------- ---------------------------------------------------------•------------------ ---------------------------------------------------------------------------- ............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued bo rto f 2he h. 1�.......... � - Date ApplicationApproved BY-------------------------------------------------------------------------------------------------- Date Application Disapproved for the fallowing reasons-----------------------•--------•----•------------------------------------------................................ ......................................................................................................... Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD 0,fiy- HEALT ..................OF......... . ..a �./.... .....:...:... Trrtifiratr_�rrof Tompliang, THI IS T 'C TI hat the Indivtidual "ewaage D.spp a S st_ h constructed ( ) or Repaired ( ) �InsLlie-, at. 4 .:' tdhj.� _ � r /s'"�t -_M �-•• •---•---------------•--------------•--•-•-•---•--------- has been installed in accordance with the provisions of :,.y6,�'7k XI, of The State Sanitar Code as described in the application for Disposal Works Construction Permit No. '-__.a '' ________________ dated'-_:'.-"-L_ ---------7..(,f....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............................................................-----••......... Inspector----------•--•-••--................................................................. THE COMMONWEALTH OF MASSACHUSETTS t BOARD QiT HEALTH 44, ...........................:...........OF....... .:. '^• ' No. ................. FEE.A... ............. Di vagal > k� TTomtrnrtinn Vrru it Permission iereby granted �>- ->:/�- -"% t ---•------------- ------•--•-•--...-----------'---•-•-•-------•-•--•-•--•------__----- to Con st et ( ' )-or Repair ( )�-a Individual Sewa :e"'Disposal Sys ni? f = l Street as shown on the application for Disposal Works Construction P na2 No...._.__. .,..... Date ......%_4._.... ---- �-- Board o Health DATE...... _°_ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS No. y'y` r� Fee J v v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4pfication for Disposal .6pstem Construction 3permit Application for a Permit to Construct( ) Repair(K Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No.5'F5 PAp RD 65t Owner's Name,Address,and Tel.No. Assessor's Map/Parcel I I q JO&LI UAOST Gul*04.Y Po C) Installer's Name,Address,and Tel.No. TO P 4 7 T Designer's Name,Address,and Tel.No. Cvewloc NIA f4 PEZ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea Sign d Date �� C Application Approved by Date Application Disapproved by Date for the following reasons Permit No.. 1 r� ^ 7 Date Issued C t No. P0/,S P r� Fee /O -- �..�...•...�- THE COMMONWEALTH'OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS , Zipplitation for Disposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( )- ❑Complete System Individual Components Location Address or Lot No. 5,95 pftw R kb 65t Owner's Name,Address,and Tel.No. 't 3AQST Cvip4y Assessor's Map/Parcel It Po P,v —A 0.1;-r fQZV I u,C kA Installer's Name',Address,and Tel.No. Sp$• ti 17"$'S 17 Designer's Name,Address,and Tel.No. cqe G l o lr t;1�r�eo�ses n�G p,,' NIA Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other-Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date / Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: - r Agreement: _•- - ' The undersigned agrees to ensure the construction and maintenance of the afore described on-site'sewage disposal system in accordance with the provisions of Title 5 of the Enviromnneental_Cod_e and not taplace the system in operation until a Certificate of Compliance has been issued by this Board of-Hea 1h. QQ ` - _ Sign dCC Date ~ lS ApplicationApproved-by -Date Application Disapproved by Date for the following reasons Permit No. ap 1 — o� 7 Date Issued 0 l --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal.system Constructed( ) Repaired(X) Upgraded( ) Abandoned( )by C A OEW(DG (—;Vr=WsklS e s WL at 59 5 PAP- e=Q. — Z)S i has been constructed in accordance f t with the provisions of Title 5 and the for Disposal System Construction Permit Nook�5 'a� dated Installer C(�� l t ��A0S&'> UZ Designer N�� #bedrooms Approved design flow- gpd The issuance of this permit shall n/oft be construed as a guarantee that the system will function,as designed. Date tom, t �3 � ? Inspector \ ' i --------------------------------------------------------------------------------------------------------------------------------------- 10 No.�� "� � Fee / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS I Disposal 6pstem Construction i3ermit K Permission is hereby granted to Construct( ) Repair( Upgrade( ) Aliandon( ) System located at .595 p Akt�R, DST8kV e4K.e5 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be c mpleted within three years of the date of this pe it. Date /H �5 Approved by ug 20 1510:25p p.1 W Commonwealth of Massachusetts -- Title 5 Official Inspection Form ►�( subsurface Sewage Disposal System Form -Not for Voluntary Assessments , §^N 585 Parker Road Properly Address A Janet Guidre _ Owner Owner's Narne = information is MA 02655 8-20-15 required for every Osterville — State Zip—Code Date of Inspection page_ Citylrown • 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 `````��SNtoFlp� % filling out forms / Mq s,°�� on the computer, 61# s9 use only the tab 1. Inspector: �s key to move your �: JAMES N not cursor-do James D. Sears _ use the return Name of Inspector = ARS c W key. �*�'• — CapewideEntprises,LLC ICI Company Name 153 Commercial Street Company Address _ MA 02649 Mashpee _ cityr town State Zip Code 508-477-8877 S1623 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. t am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority B-20-15 AlpeCtDI'S Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design Flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the.DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. �o t5ins-3/13 Title 5 Official Inspedion Forn:Subsurfeoe Dioposol System.Pago 1017 • r i { Aug 20 1510:25p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _585 Parker Road Property Address Janet Guidrey_ Owner Owners Name information is psterville _ MA 02665 8-20-15 required For every page. Citylrown State Zip Code Date of Inspection B. Certification (coat.) Inspection Summary: Check A,B,C,D or E I 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: The system is a 1500 Gal Tank D Box and two pits. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no'or"not determined" (Y, N, ND)for the following.statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. i A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): i I j i t5ins•3n 3 Tilts 5 MUM Inspection Form:SuSourfma Sewage Disposal System-Pogo 2 al 17 Aug 20 1510:25p p.g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � i 585 Parker Road Property Address Janet Guidrey Owner Owner's Name information is MA 02655 8-20-15 required for every Osterville State Zip Code Date of Inspection page City/rown B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpstalarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box- System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NP (Explain below): obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N 0 ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: i ❑ 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 wiith 310 CNIR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: i ❑ 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 15ins-Y13 TKs 5 Official Inspeccon Form Subsurracs Sawage Disposal System-Page 3 of 17 { Aug 20 1510:26p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 585 Parker Road Property Address Janet Guidrey Owner Owner's Name information is MA 02655 8-20-15 required for every Osterville page CityrTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system Is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No I ❑ ® 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 Cl ® Liquid depth in sad is less than 6"below invert or available volume is less than'/z day flow f i73 15ins•3113 Title 5 Orfidel Inspection Form:Subsurface Sewage Oisposal System•Page 4 of 17 i Ef Aug 20 1510:26p p,5 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface sewage Disposal System Form -Not for Voluntary Assessments r 585 Parker Road Property Address Janet Guidrey Owner Owner's Name information is Os MA 02655 8-20-15 required for every Stale Zip Code Date of Inspection page. Cityrrown B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped. ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ®0 An rtion of a cesspool or privy is less than 100 feet but greater than 50 feet Y Po from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached'to this form.] 0 ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No j i E ❑ ❑ the system is within 400 feet of a surface drinking water supply l I ❑ ❑ 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 j 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. l 15ins•31'.3 Title 5 Official Inspection Form:Subsurface Sewage Disposal Srslsm•Page 5 of 17 Aug 20 1510:26p p 6 Commonwealth of Massachusetts Title 5 Official Inspection Form -r °, Subsurface Sewage Disposal System Form Not for Voluntary Assessments 585 Parker Road Property Address Janet Guidrey Owner Owner's Name information is Osterville _ _MA 02655 B-20-15 required for every -- State Zip Code Dale of Inspection page. CityITown C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? El ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding"the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health- ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information i Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual):. 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 I 15ins•3113 Title 6 Qlricisl Inspection Form:Wbswaca Sewage Disposal System•Paue 0 of 17 Aug 20 15 10:27p p.7 Commonwealth of Massachusetts- Title 5 Official Inspection Form 'I Subsurface Sewage Disposal System Form- Not for Voluntary Assessments y 585 Parker Road Property Address Janet Guidrey --- --- Owner Owners Name information is MA— _02655 8-20-15 Osterville required for every Date of Inspection page. city/Town State Zip Code D. System Information Description: The system is a 1500 Gal Tank D Box and two pits. .. 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No 2013-97,000Gals Water meter readings, if available(last 2 years usage(gpd)): 2014-81,000 Gal's Detail: Sump pump? ❑ Yes ® No NA Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment Design flow (based on 310 GMR 15.203): Gallons per day(gpd) i Basis of design flow (seats/persons/sq.ft., etc.): j I Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No i Water meter readings, if available: 15ins•3113 Title 5 official inspedion Form:Subsurface Sewage Disposal System•Page 7 of 17 I I Aug 20 1510:27p p,8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 585 Parker Road Property Address Janet Guidrey Owner Owner's Name information is Osterville MA 02655 8-20-15 required for every Cityffown State Zip Code Date of Inspection page, D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 09 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval ❑ Other(describe): i t5ins-3113 TCIe b ammal Inspecoon Fon[r.sw5urtaca Sewage Dimpo"I Systom-Page B of 17 i I Aug 20 1510:27p p g Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 585 Parker Road — Property Address Janet Guidrey — — Owner Owner's Name information is Osterville MA 02655 8-20-15 required for every Page City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Permit 76-83 D Box is New 8-2015. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑cast iron' ®40 PVC ®other(explain): Distance from private water supply well or suction line. feet Comments(on condition of joints, venting, evidence of leakage,etc.): Pipeing is 4" PVC SCH -40 &SCH-20. — Septic Tank(locate on site plan): 14" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) i If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal.Precast H-10 Sludge depth: 2" tSins•3A3 Title 5 Official Inspection Fomr.Subsurface Sewage Disposal System Page 0 of.17 ii I I Aug 201510:28p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 585 Parker Road Property Address Janet Guidrey Owner Owner's(dame information required for every Ostervllle MA 02655 8-20-15 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and covers at 14"below grade. In and outlet tees- No sign of leakage or over loading. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): I a Dimensions: ---- i Scum thickness Distance from top of scum to top of outlet tee or baffle j i Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: b Date t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 i� Aug 20 1510:28p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 585 Parker Road Property Address Janet Guidrey Owner Owner's Name information required for every OstenAlle MA 02655 8-20-15 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Comments(on pumpingrecommendations, inlet and outlet tee or baffle condition structural integrity, 9 Y. liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan).- Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: - Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): i ii i i i *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No j 1151ns 3113 Title 5 Dtficia;Inspection Form;Subs;;rtece Sewage Disposal System-Page 11 of 17 i I i Aug 20 15 10:28p p.12 Commonwealth of Massachusetts On Title 5 Official Inspection Form rri Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 585 Parker Road Property Address Janet Guidrey Owner owner's Name required for every information is required MA 02655 8-20-15 require page. Citylrown 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 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc.): D Box is new 8-2015 Box is 28"Below grade w/cover at 6". Tow line's out. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No` Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): J * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: i I i I i, t5ins•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Aug 20 1510:29p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 585 Parker Road Property Address Janet Guidrey Owner Owner's Name information is required for every Osterville MA 02655 8-20-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 Elleaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: - ---- ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two H-20 Precas pits. Both pit's are 26" below grade. 6'water in pit's- No sign of over loading or solid carry over. No high stain line. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No (Sins-3113 Title 5 Official Inspection roan:SubwAace Sew$qa Disp osal Syslem•Page 13 of 17 Aug 20 1510:29p p.14 Commonwealth of Massachusetts _ Title 5 Official Inspection Form F _ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments N 5135 Parker Road Property Address Janet Guidrey Owner Owner's Name information's required for every Osterville MA _ 02655 _ 8-20-15 page. Ciry St /Town ate Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): j I i i i tEins-3/53 Tile 5 Official Inspection Forth:Subsurface Sewage Disposer System-Page 1.4 of I7 Aug 20 1510:29p p.15 Commonwealth of Massachusetts - Title 5 Official Inspection Form a = - Subsurface Sewage[)Isposai System Form-Not for Voluntary Assessments `r. 585 Parker Road J Property Address Janet Guidre --- Owner Owner's Name MA02655 8-20-15 information is osterville — - required for every - State Zip Code Date of Inspection page Citylrown D. System Information (cont.) es to Sketch Of Sewage Disposal System: Provide or benchmarks. Locate all posal within 100 feet including olcate at least two permanent reference landmarks where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below drawing attached separately 142 i CK 13Ll f S_ R-Z = 36 o 41 = -5 /` l Title 6 Of el hVecbon Form:Suo—toce sewage D4osai system-page;5 of 17 Aug 20 1510:30p p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 585 Parker Road Property Address Janet Guidrey Owner Owner's Name information is Osterville MA 02655 8-20-15 required for every -- page. Cityrronnl State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth t high ground.water 12'+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 2-20-76 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: i i You must describe how you established the high ground water elevation: T.H.on Design Plan 2-20-76 no G.W. at 12'. Bottom of pit at W below grade. Bottom of pit at 4' j above T.H. Depth i i i Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-3J13 rifle 5 Official tnspection Form:Subsurface Sewage Disposaf System-Page 16 of 17 i Aug 1201510:30p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -- 585 Parker Road Property Address Janet Guidrey Owner Owner's Name information is required for every Osterville MA 02655 8-20-15 page, Citylrown state Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C. D,or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—.Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I i i i i i i II E tSins•3l13 Title 5 011dal Inspection Form Subsurface i Sewage Disposal System•Page 17 ai 17 i i i I j f 1 i ---.. 4 � E [ i e h, 1 {�1 i w S { _ tA oo •mac �. �.--� z � `?"-�--_„�•--- LU6 r rn n� I CERTIFY THAT THIS PLAN IS IN ACCORDAMtE .? ITH HE CURRENT ZONING LAWS Of' TMt- 'Nk DATE lu No. 381 `tea-. - ,..,,� �'�-�•' ,....ti z._ / M ��,�_' , � ri,.�. 1..+� .`..r" ��y�� r.t... ✓• i',..--' t"`','°"� w' .� �.., --... ��`�c r• �i"4'*s S 0"1 7.h. .# I ✓ �,. ° i ,r. '' 7 r71r� 1 �,` " r" \ 1 R �..�J - fT "- � J. 1, .`""" �� r�"� • 4°%h �r rPI` '�. Y^ r --E.,. ,. -.� � � � ,'�,dt«�;Lam,,, .,..,may. t_ ,.. ' i� -� �`L�. // �-ry ► � e jv,. r •.. 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