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HomeMy WebLinkAbout0117 PARSLEY LANE - Health 117 Parsley Lane Osterville P A = 165 112 f achusetts Commonwealth of Mass �n Title 5 Official Inspection Form , l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -a 117� Parsley Lane y �.1 Property Address t2 Suzanna Golmanavich u'+ Owner Owner's Name information is required for every Osterville Ma 02655 9-19-18 -, page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 61 333' on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 r� Company Address Sandwich Ma 02563 City/Town State Zip Code rya (508)477-0653 S 113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority _ z 4. ❑ Fails Brett Hickey °°�°�'"" 9-19-18 `-Oze:N119.08.3C 0):35:QI-0aGV Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of _ 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Parsley Lane v Property Address Suzanna Golmanavich Owner Owner's Name information is required for every Osterville Ma 02655 9-19-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. - Comments: The system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no' or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts �= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Parsley Lane Property Address Suzanna Golmanavich Owner Owner's Name information is required for every Osterville Ma 02655P 9-19-18 - page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): El The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: - ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �e p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Parsley Lane Property Address Suzanna Golmanavich Owner Owner's Name information is Osterville Ma 02655 9-19-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ' **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: x e •. 4 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections:' Yes No ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 99 p t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Parsley Lane V Property Address Suzanna Golmanavich Owner Owner's Name information is Osterville Ma 02655 9-19-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ El than depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ O Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: [j E] Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. I For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. . Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 16 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Parsley Lane Property Address Suzanna Golmanavich Owner Owner's Name information is required for every Osterville Ma 02655 9-19-18 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for aff inspections: Yes No El ❑ Pumping information was provided°by the owner, occupant,or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ El this 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 El ❑.' available note as N/A) ❑ n Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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 El, 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: El ❑ Existing information. For example, a plan at the Board of Health. [I El approximation in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Parsley Lane V� Property Address Suzanna Golmanavich Owner Owner's Name information is Osterville Ma 02655 9-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330/gpd Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection El Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes [E No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: ***2016-119,000gallons 2017-105,000gallons*** Sump pump? ❑ Yes No Last date of occupancy: currentDate t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 } Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Parsley Lane Property Address Suzanna Golmanavich Owner Owners Name information is Osteryille Ma 02655 9-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): - Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped 1 year ago Was system pumped as part of the inspection? ❑ Yes ❑E No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 117 Parsley Lane Property Address Suzanna Golmanavich Owner Owner's Name information is Osterville Ma 02655 9-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2009 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): .4, Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Parsley Lane tJ Property Address Suzanna Golmanavich Owner Owner's Name information is Osterville Ma 02655 9-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - 6. Septic Tank(locate on site plan): 3' Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon - 4„ Sludge depth: 32" Distance from top of sludge to bottom of outlet tee or baffle Orr Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum rto bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,. liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. f t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 s Commonwealth of Massachusetts 1� Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Parsley Lane Property Address Suzanna Golmanavich Owner Owner's Name information is Osterville Ma 02655 9-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): NA Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene, ❑ other(explain): Dimensions: Scum thickness - Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): - '. NA Depth below grade: Material of construction: ❑concrete - ❑ metal ❑fiberglass ❑ polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 16 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Parsley Lane v Property Address Suzanna Golmanavich Owner Owner's Name information is Osterville Ma 02655 9-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0'r Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. - r r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c � Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Parsley Lane v Property Address Suzanna Golmanavich Owner Owner's Name information is Osterville Ma 02655 9-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) r 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes No* Alarms in working order: ❑ Yes R No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: (2) 500 gallon 0 leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: - - ❑ leaching fields number, dimensions:- ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc*•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Parsley Lane V Property Address Suzanna Golmanavich ; Owner Owner's Name information is Osterville Ma 02655 9-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leaching was in working order and was dry at time of inspection. 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ .Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): A t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .......... 117 Parsley Lane Property Address Suzanna Golmanavich Owner Owner's Name - information is Osterville Ma 02655 9-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate orr site plan): NA Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 4 l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 T • t Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Parsley Lane a v Property Address Suzanna Golmanavich Owner Owner's Name , information is Osterville Ma 02655 9-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information .(cost.) 14. Sketch Of Sewage Disposal System: s. ` 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 Asbuilt Ground Water Profile Grade f . 4' A l3 ' LU Leaching chamber Patio +.. >138 Al-77' A .° A2.88' z A3.93'' 131-26` V 132-38' 133-4r ground water t5insp.Goc•rev.7/.26/2018 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 117 Parsley Lane Property Address Suzanna Golmanavich Owner Owner's Name information is Osterville Ma 02655 9-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope d ■❑ Surface water ❑WE Check cellar ❑■ Shallow wells Estimated depth to high ground water: No GW @ 138"- feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record June-25-2009 If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators installers-(attach documentation) ❑ Accessed USGS database-explain: . r. You must describe how you established the high ground water elevation: . A plan on file with the Board of Health was used. _Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 117 Parsley Lane Property Address Suzanna Golmanavich Owner Owner's Name information is Osterville Ma 02655 9-19-18 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑■ A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed &Dated and 1, 2, 3, or 4 checked ■❑ C. Inspection Summary: 1, 2,.3, or 5 completed as appropriate - 4 (Failure Criteria)and 6(Checklist)completed R D. System Information: ' For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 �avn :Barnstable Regulatory Services o - Tho M'V.Geiler,Director BAJRMNsrnstar MASEL We Health Di" visian �f1 M Thomas McKean,Director 200 Main:Street;Hyannis--. Office: _SQ8-862-4644 . Fax-. 6304 508-790= w Installer=&:Designer:Certification Form Date:. � S �. Sewage PerQut# Assessor's Map�Parcel Designer: C - Address: +1 l - e— Address: !� . �"_ CP�r' - � On �;�-: ��- was issued a permit to,install a (date) L Y septic system at : t� e � _ V1 112.based on a:desi drawn-b 5-.0 _ (designer) I certify that-the septic system referenced above was. _substantially according to the design, .which may include minor-approved changes such as aateral:relocation'ofahe distribution-.box and/or:septic tank: I certify that the septic:system,referenced.above was.installed-with major.changes (i e greater than 10' lateral_relocation of the-SAS:or.any_vertical relocation of:any_component -of the septic system)but'in aceardance wiffState&I ealRegulations `Plan runs on c certified as-built by designer to follow. OF A� s ZN A� ' �o DAVID GN L o 'D. (Installer's Signature). COUGHANOWR -N _ No. 1093 Q �ciSTEP� (Designer's ignature) (Affix.Designer's Stamp Here) PLEASE- RETURN TO- .BARNSTABLE PUBLIC HEALTH .DIVISION: CERTIFICATE OF COMPLIANCE WILL NOT--BE ISSUED UNM BOTH THIS -FORM AND AS-BUILT CARD -ARE-:::::-: RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU._ Q:Healtb/Septic/Designer Certification Form 3=26-04.doc TOWN'OF BARNSTABLE L-OCATI'ON � r$ �L �/ Z--A SEWAGE# O ` ? ,VILLAGE �� '1� ASSESSOR'S MAP&PARCEL -I �- INSTALLEW&NAME&PHONE NO. a �, j gus d �^- `7 7 C - -9 SEPTIC,TANK CAPACITY ) C LEACHING FACILITY:(type). ()b j ." .� (size) NO.OF BEDROOMS . OWNER 92 f PERMIT DATE: -1 09 COMPLIANCE DATE: dl, a— C� Separation Distance Between the: Maximum Adjusted Groundwater Table to the ottom of Leaching Facility Feet Private Water Supply Well and Leaching Fac' ity.(If any wells exist on site or within 200 feet of leaching fa lity) Feet Edge of Wetland and Leaching Facility f any wetlands exist within 360 feet of leaching facility) Feet FURNISHED BY l - � f 7 7 f 117_ Parsley Osterville,Mass. Q � . i I 0. vo M-C/ N.c�xw — l L, 7 ) Fee kY )00• r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS . Yes ftpficatiou for ]Disposal *pstem Construction permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Locati Address or Lot No. O ner's a Address and Tel.N .S� 111 `51�Ls� -fit/i . 7-0-w ,if Sc.)Z. Lnev, 0-®I&Z e'CL v 101 Assessor's Map/Parcel `a 11 �.. _rv�I1� Installer e, dd ressC and a /► Designres Name Address,and Tel.NoFU�'-3(©4• �f No.510 ? I ,Steel.yO d t (l�. ''i`3`1 1�� �C�2. �J►Cam. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder Wp 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) Zrn ne-.0 1"�'l �' SQjt✓ S - 40 elV,s `1c� 7'eu�, k ETC -3 t(o® 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 B-Y'ar—dof Health. /7 SiaR� A Date ` " a- ApplicationApprovedb Date Application Disapproved by Date for the following reasons Permit No. Date Issued Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABt1;"MASSACHUSETT=S Yes �4pfiiation for Oisposaf *pstrm Construction i3ermit Application for a Permit to Construct O Repair(Y) Upgrade( ) Abandon( ) ❑ stem complete Sy stem y El individual Components Locatio Address or Lot No. Owner's Name,Address,and Tel.No 4S_ a0• `J14 11`1 4�'S1 LC> , C.�S�e-Cv� 1(�.. 3C7S ►h 9 Guz ov. ,V, &,61 f"ax)a.0 01 Assessor's Map/Parcel ` - I 1 Z pO-T (e_-i 5S3e. U t 1(� Installer's Name,Address,and Tel.No -7 7 S 77(o Designer's Name,Address,and Tel.Nof C)�--3(may.OE q 4 Pc� n� S� C:.. .�E c v►C_�- lam ,v sci e. cs'r Type of Building: "- Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(leg) 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) C1 SV .0 tQ_ (1e-,-o 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 Environm I ental Code and not to place the system in operation until a Certificate of i Compliance has been issued by this Car Health. Si d Date / Z Application Approved b Date Application Disapproved by Date for the following reasons Permit No. / Date Issued t� THE COMMONWEALTH OF MASSACHUSETTS �t BARNSTABLE,MASSACHUSETTS Certificate of Compliarrte THIS IS TO CEyRTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded( ) Abandoned )by 4f1 Y"l E� 9.{ l SK 1>0)i C, V t C 0. at 11� 1, a S-k_-f V i i 1 C— has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.CQM q—)'??dated Installer Designer r q"- L t j #bedrooms - Approved desi flow�f `3 gpd The issuance of this per; it lall not be construed as a guarantee that the system will tidn�as designed: Date `'� � (� Inspector �/ �_f -2 No. r7 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION=BARNSTABLE,MASSACHUSETTS BiSpoSaf Opstem Construction permit Permission is hereby granted t onstruct( ) Repair(x) l�Upgrade( ) Abandon Q ( ) System located at s� _. 5'T J i t 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. 9h Provided:Constructiof mu%t be completed within three years of the date of thiQb it. f Date ?/�`0� Approve a Town of Barnstable P# Department of Regulatory Services STABM : Public Health Division - - DateMAM �p i639 �� 200 Main Street,Hyannis MA 02601 - - _ ren►act" - - - - -- • -.- - . .. . -Date Scheduled' l r Time l Fee Ud Pd: Soil Suitability Assessment for Sewq e D'sposal PerformedBy:Do, LVUG`1{���� v - Witnessed By: { ';-LOCATION& GENERAL INFORIVIAT_ION' Location Address " /^ pl L kte.._- Owner's Name 65C' y y Gl 1 Gal ty19l40 L/G Address �rKC. / 05ijler-V It e, Asses4or's Map/Parcel: �l l 21 Engineer's Name lJ�V i'd CB bc�t�1 NEW CONSTRUCTION RE PAIR PAIIi V _ Telephone# Land Use P luhe��l , Slopes(%) ` !b _Surface Stones �'`Q a mm Distances from: Open Water Body`10ft Possible Wet Area ft r ft Drinking Water Well �dv �. ft . Drainage Way } ft Property Line t } ft l Other ft t { - SKETCH:(Street name,dimensions of lo4 exact locations of test holes Y&perc tests,.locate wetlands in proximity to holes) PARSLEY - LANE r i ffU NDWATER ADJUSTMENT `I I NG GROUNDWATER LEVEL ON, TOWN OF BARNSTABLE CI I PARTMENT RECORDS '^ INDICATED GW 5,00 INDEX. I I ZONE WELL MIW-29 1 I READING DATE MAY. 2009 I READING 7.4 I ADJUSTMENT 2.3 ®Z I -1 ADJUSTED GW 7.3. Parent material(geologic) pro(?1GU al 1 Ouf w S Depth to Bedrock Y 1p11� Depth to Groundwater. StandIn Water in Hole: e g Weeping from Pit FpCc Estimated Seasonal High Groundwater See PETER WNATION FOR SEASONAL HIGH WATER TABLE Method Used: SCe oy C Depth Observed standing in obs.hole: in, Depth to soil mottles: side of obs.hole: ln, aroundwater Adjustment ft. Index Well#eIj pth to weeping Reading nUate:, index Wel11eYCLAdj.-factor.— Adj:drtwndwnter l ve1— --- -— PERCOLATION ThST bate 44 01 Time Observation i Hole# Q Time at 9" Y11 - Depth of Pero ` t t1 Time at 6" h y 61° g Start Pre-soak Time @ � .: Time(9„4) End Pre-soak 2 ►nP ��U Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) 'V oltP bser e ioOriginal: PublicHea C n Back ---------- **1W percolation test is to be conducted Within'1001. of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. Q:\.SEPTICIPERCFORM.DOC • --s I _ DATE 'OF-TEST: "" JUNE 24`2009 SOIL TEST ` O APROVED WITNESSEDI BY VALUATOR: DAVID D.DAVID STANTON. HEALTH RTH#461 DEPT. ' PERC- NUMBER: 12607 1NO TEST PIT PAARENOTUMAATERIA EPROGLACA LD OUTNCOUNTE UTWASH PERC AT 84-tn - 2 MIN/INCH IN C�SOILS _ ELEVATION DEPTH SOIL` _ . . USDA SOIL.- _ SOIL COLOR, SOIL _ OTHER 51.40 (INCHES) HORIZON TEXTURE (MUNSELL) t MOTTLING 0-15 FILL1 - 15-18 0 - LOAMY SAND - -- — 10 YR 2/1 - ; NONE - FRIABLE 18-22 A i LOAMY SAND 10 YR 3/3 NONE FRIABLE 47.65 22-45 B - _ - LOAMY SAND-- 10-YR 4/6- NONE LOOSE 45-138 C MEDIUM'SAND' 10 YR 5/4 • ] -NONE LOOSE 39.90NO i TEST PIT 2 PAARENOTUNDWATE MAATERIA EPROGLAC ALD OUTWASH Y5 `2 'MIN/INCH IN C SOILS — t � ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL - - OTHER (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 50.65 0-8 AP LOAMY SAND 10 YR 2/2 NONE FRIABLE 8-38 B LOAMY SAND 10 YR 4/4 .( NONE LOOSE 47.48 38-132 C 'j _ MEDIUM SAND 10 YR 6/4 NONE LOOSE 39.65 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling . (Structure,Stones Boulders. Consistency,%QcgyeI t' Flood Insurance Rate Man: Above 500 year flood boundary No—// Yes- _ ` Within 500 year-boundary No V' Yes - - FWithin L00 year4 flood.boundary No�,• Yes a Depth of Naturallybccurrine Pervious Material Does at least four feet of naturally occurring pervious material exist it all areas observed throughout the area proposed for the soil absorption system? If not,what is the.depth of naturally occurring pervious material? Certification c I certify that on 5 (date)I have passed the soil evaluator exams ation approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the re'quire(dtraining,expertise and experience described in 310 CMR 15.017. Signature �.4 I. L-SC 41e.0` Date Uvie 2-�, Zo� Q:VSBPTIC\PERCFORM.DOC DATE: 4/23/03_--- L K4,rc- PROPERTY ADDRESS: 117_Parsley xay Osterville,Mass. -- -------------------- 02655 ------------------------ On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 3-6 ' X8 ' block cesspools. RECEIVED Based on my Inspection, I certify the following conditions: N1AY 0 6 2003 2 . This is not a title five septic system. TOvvf\OF-BARNSTABLE HEALTH DEPT. 3 . This is sewage system. ( 1969) 4 . The sewage system is in proper working order at the present time. 5 . Pumped both main cesspools. 6 . Cesspools are presently structurally sound. 7 . No signs of water intrusion. SIGNATURE: WL Name:-J.P.- Macomber Jr_.______ Company: Joseph_P_ Macomber_& Son , Inc . Address: Box 66 t Centerville , Ma .-02632-0066 Phone: 508-775-3338 THIS CERTIFICATION DOES NOT CONSTITUTE,;A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 • 1 I s� - II � l— COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1 1 7 Parsley Way Osterville,Mass, Owner's Name: Roy Neeven Owner's Address: Same Date of Inspection: 4/2 3/0 3 Name of Inspector: (please print) Joseph P. Macomber Jr, Company Name: Joseph P. Macomber & Son Inc Mailing Address:_Box 66 Ct-ntPrvi11P Ma 02632 Telephone Number: 508-775-3338 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 J to Section 15.340 of Title 5(310 CMR 15.000). The system: y/Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority 2Fas Inspector's Signature: Date: d The system inspector shal 7mit 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. Notes and Comments t ****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: 11'7 Parsley Way Osterville,Mass. Owner: Roy Neeven Date of Inspection: 4/23/03 Inspection Summary: Check A,B,C,D or h/ALWAYS complete all of Section D System Passes: dz) 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 sewage systetn is in proper workinq order at the present mime_ B. System Conditionally Passes: �� One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. .��The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: - &e-Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed 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 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 1 7 Parsley Way Os ervi e,Mass. Owner: Roy Neeven Date of Inspection: 4/2 3 /0 3 C. Further Evaluation is Required by the Board of Health: -V-D— 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: ,dz) Cesspool or privy is within 50 feet of a surface water �f Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. i(lD The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 4 Xhe system has a septic tank and SAS and the SAS is less than 100 feet but 5 feet or more from a private water supple well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: This is a sewage system.The system consists of three Xblock cesspoo s. -main pool for the grey water and one main pool for the bat .The two main pools overflow to the center pool. 3 Page 4 of I 1 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:117 Parsley Way Osterville,Mass. Owner: Roy Neeven Date of Inspection: 23/03 D. System Failure Criteria applicable to all systems: You must indicate yes"or"no"to each of the following for all inspections: Yes No/ _ P//,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 ���tlrl Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ squid depth in cesspool is less than 6"below invert or available volume is less than h day flow y Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number /or times pumped I, 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 I 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 forma _Q (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no/ the system is within 400 feet of a surface drinking water supply v the system is within 200 feet of a tributary to a surface drinking water supply _ 7the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— Zone 11 of a public water supply well IWPA)or a mapped 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 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 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 1 7 Parsley Way Osterville Mass. Owner: Roy NegVlgri Date of Inspection: Check if the following have been done.You must indicate`yes"or"no"as to each of the following: 4 Yes No Pumping information was provided by the owner, occupant, or Board of Health 1/ 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 a<9 -Z _ Was the facility or dwelling inspected for signs of sewage back up? ' Z _ Was the site inspected for signs of break out? -Z- Were all system components,"@*Cluding the SAS, located on site? /kil& 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. v — 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)] I 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:117 Parsley Way Osterville,Mass. Owner: Roy Neeven Date of Inspection: 4/2 3/0 3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):°_ Number of bedrooms(actual): �7 DESIGN flow based on 310 C1 15.203 (for example: 110 gpd x# of bedrooms): X// Number of current residents: �1 Does residence have a garbage grinder(yes or no): C.e r7 Is laundry on a separate sewage system yes or no):�D [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): 06 Water meter readings, if available(last 2 years usage(gpd)): 2 0 01 —1 2 7, 0 0 0 ga 11 ons=3 4 7 . 9 5 GP Sump pump(yes orno):_Vp 2002-114, 0 gallons=312 . 33 GPD Last date of occupancy: Sprinkler System is present. . COMM ERCIAlANDUSTRIAL Type of establishment: 44 Design flow(based on 310 CMR 15.203): .),A gpd Basis of design flow(seats/persons/sgft,etc.): 144 Grease trap present(yes or no):Al Industrial waste holding tank present(yes or no):AM Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use:- A2A OTHER(describe): A)4 GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):LLS If yes, volume pumped: L? Za gallons-- ow was uangt�.P,pu e lete��fined? Reason for pumping: UV � ' q7' dd r .(/4Y��l�`�' TYPE OF SYSTEM t)Septic tank,distribution box,soil absorption system Single cesspools Overflow cesspool 42 Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) 4,20Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from sysltgm owner) �UTight tank � Attach a copy of the DEP approval yv Other(describe): It,?4 Approximate age of all components, date installed(if known)and source of information: '�,CpJ�Q el Were sewage odors detected when arriving at the site(yes or no):WP 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:117 Parsley Way Osterville,Mass. Owner: Roy Neeven Date of Inspection: 4/2 3/0 3 BUILDING SEWER(locate on site plan) Depth below grade: >rj� `� 4" Orangberg pipe through out Materials of construction: _cast iron &La40 PVC Mother(explain): the sewage system. Distance from private water supply well or suction line: /d'li'' Comments(on condition of joints, venting, evidence of leakage,etc.): Joints appear tight_Nn evid n e r)f leakage The system is vented through the house vents. SEPTIC TANKi9&t'.(locate on site plan) Depth below grade: A..)h Material of construction:,j)concrete �A ietaW/E fiberglass polyethylene A1A#other(explain) � ,f/,4 If tank is metal list age:&d Is age confu-med by a Certificate of Compliance(yes or no):kb(attach a copy of certificate) Dimensions: A)A Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: M4 Scum thickness:_)L Distance from top of scum to top of outlet tee or baffle: A)h Distance from bottom of scum to bottom of outlet tee or baffle: A)iQ How were dimensions determined: AZ)4 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Reptir tank is not present_ GREASE TRAPlocate on site plan) Depth below grade:2 Material of constructi on:A WconcreteA//9 meta W17,fi berglas s&/Op o lye th yl en*VZO other (explain): Dimensions: AIW 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.): C;rpasp trap is not praRant 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 1 7 Parsley Way Ostervi e,Mass. Owner: Roy Neeven Date of Inspection: TIGHT or HOLDING TANK,dfot/G(tank must be pumped at time of inspection)(]ocate on site plan) Depth below grade:V Material of construction: 40 concreteA/A metal OA fiberglass etM Polyethylene j)4 other(explain): d4 Dimensions: -VA Capacity: Im gallons Design Flow: NA gallons/day Alarm present(yes or no): A,�A Alarm level: ,0,,/t- Alarm in working order(yes or no): 4/rtt Date of last pumping: VA Comments(condition of alarm and float switches, etc.): Tight or Holding tanks are not present. DISTRIBUTION BOxrrg Le(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.): 6; str; bution box is not present. PUMP CHAMBER &Y,(locate on site plan) Pumps in working order(yes or no):— Alarms in working order(yes or no): /r Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Pump chamber is not present. 8 r. Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C i SYSTEM INFORMATION(continued) Property Address:1 1 7 Parsley Way s t ervi e, ass. Owner: Roy Neeven Date of Inspection: 3 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 3-6 ' X8 ' bloc cesspools i If SAS not located explain why: LL]Cai Pd' SPP page 10 T e ' leaching pits,number: ] VO leaching chambers,number:_Q leaching galleries,number: 0 _ _j2j� leaching trenches,number, length: Q leaching fields,number,dimensions: Z) overflow cesspool,number: L_ _/M innovative/altemative system Type/name of technology:, Prior 1_978- Code ( 1:9.b:9 ), Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vdgetation, etc.): Loamy sand to medium coarse sand No signs of hydraulic failure ar pr)nding_ Soils are dry Vegetation is normal Pumped twocools at time of inspection. Both were structurally sound and showed no signs of water in tt��S� ion. CESSPOOLWX (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Q Depth—top of liquid to inlet invert: �Q Depth of solids layer: Depth of scum laver: i9 Dimensions of cesspool: IVA Materials of construction: WO Indication of groundwater inflow(yes or no):&-d Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Same as above PRIVY(locate on site plan) Materials of construction: Dimensions: ZIA Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy is notpresent 9 Page 10 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 1 7 Parsley Way Osterville.Mass. Owner: Roy Neeven Date of laspection: 4/2 3/0 3 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public.water supply enters the building. i a 01' 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: 117 Parsley Wad Osterville.'MaGG Owner: Roy Neeven Date of Inspection: 4/21 j n i SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4d feet s Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked, date of design plan reviewedNA YES Observed site(abutting property/observation hole within ISO feet of SAS) NO Checked with local Board of Health-explain: N A YES Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: http: //town,barnstable,ma.us. You must describe how you established the high ground water elevation: Used: Gahrety & Miller. 12/16/94 Ground water elevations above sea level. Used: USGS: Observation well Data June 1992 Used: USGS_ Tpnhniral Bull in —000-1 Plate #2 Annual ranges of around wat-PrT el.FVraunfiieGn Taniiary 1992 - 3-6 ' X8 ' block cesspools i Groundwater]d Feet Below Bo Groundwater Ad 1. ttom of Pit High Gjustment• ) 8 ft per Fnmpter Method Therefore, the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is 21, feet. 11 y •r.•r.TSB•+r+<<'rs�.Tr' *i►rmr•rtsnrtrnrt rerrrr..r.:-n.•rera.r:+n+e+-:merrniar+a�rcrers _ .. �1 0 t' Barnstable TOWN OF BOARD OF HEALTHSl)I)SURFACF 9EHACF DISPOSAL SYSTEM IN9I'ECTION FORM - PART D •- CERTIFICATION "t•T• .•♦— ,tt��.�T.T.T:°1'1}.TJI1Tf.'4Tfif'iTT.T1:r'Tr'tfTT7�1'R1R�T4ATCMt/RtCfIRIRO7tTfMMMiRfnTsii"R1tiq� �t•.�rrT•Tr•1• -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS117 Parsley Way Osterville,Mass. ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Roy Neaven PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son Incrw COMPANY ADDRESS Box 66 Centerville Mass . 02632 Street Town or Crty State LIP COMPANY TELEPHONE ( 5081) 775 - 3338 FAX ( 508 1 790 - 1578 !T • CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at ®rlecoinmendat' his address and that the information reported is true , accurate , and omplete as of the time of inspection . The inspection was performed and any ions 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 : �v System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healL)I or, the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA sectioll of this form . System FAILED* The inspection wtlic)i I have con trcted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 3.10 CMR 15 - 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , aInspector Signatur2 - DateLL!� d hd copy of this certification must be provided to the OWNER, the BUYERere applicable ) and the I30ARD OF HEALTH, * It the inspection FAILED, the owner or"" perator shall u pg 'within one year or the date of the inspection, unless alloweddorthe requiredm otherwise as provided in 3,10 ChIR 16 . 305 . partd .doc t. CONTOURS LANE BENCH MARK EXISTING - - - - - - - 50 PARSLEY INGER e N MINIMAL GRADING PROPOSED 2 TOP CORNER BULKHEAD* � � sOr LANE o / E ELEVATION = 54.22 52 ` < z w BARNSTABLE GIS DATUMOCD ❑TW q C� BUJ 0 J C<7 m n / / V OSTERVILLE. MA m LOCUS MAP >� NOT TO SCALE. m d WATER \IMF o m T-z o w / O 6 .i GATE �T H F N w (Jl / / ° --53— \� \ W��� ' = ui � <3 - LEGEND o n-❑❑� 0 cwn❑ / �� 9 �/ \ - F_ JT❑� P-.J Z 3 °wo / Q / LOT 67 �� 1500 GALLON O - ❑ J U z (A J �--� w/ SEPTIC TANK r2 <(n<� Qw w z ,, cnco `�/ l AREA. = 16271 SF +- l wu �3 W > DT Jw W} U (n 0 \ EXISTING LEACH O p w ''x d X < _j 0Z � N o T �/ �'�/ I / PIT/CESSPOOL CD m `�< W w w=~ mF (� v ° I / UTILITY POLE o z� `� .. w , -1 U < m :5: w , W � u-w m (n / 3 STj TEST PIT® D-BOX O Q J :i ::>>: / �' �/ �QO DECIDUOUS CONIFEROUS CD W OJ X �' eT�� jn w GARBAGE GRINDER TREE oo�o TREE W W w< ry `` / \ \/ 4 IS NOT ALLOWED Q6e 12-M *2-P O z ry�� m N / < ���^' G /�n WITH THIS DESIGN. NUMBER REFERS TO DIAMETER IN Q Q Ln w 'I ' r` \ a 5�2j'VO/� INCHES. LETTER DENOTES TYPE. W Z I = (� / X\ 53 �/ O-OAK M-MAPLE P-PINE C-CEDAR cif 0 IL X _ F�6_-) 00 15-0 b / �� N OF Mg �`SNOF 4me , 'u o ° � DAVID y� �� DAVIDzLu 51 D. N D. m cn m / 52 COUGHANOWR COUGHANOWR O 3 Z z / WHALE tik kw No. 1093 W Z O I ,n \ ti ti� �F �0 `r0 ��CENS�� wo I- zt / aD 24ftx12.5FLx2FL G1sTE� Pt0 �� co ❑ m v L� / <C�1s-o ourAN � rP-I � LEACHING GALLERY sq r �' �vAL S L.SC �a U m \ q Q �51 �_-00q Jk e \�� d�/ �� ° roe '2>rt e SEWAGE DISPOSAL SYSTEM PLAN W w z 10-0 �® �� -TO SERVE EXISTING DWELLING z w cn O 5 `�'� r \ i EST. JOSEPH AND SUZANNA ~� J �L m -� -�� 50 GOLMANAVICH L 3 << W �� ��' OWNERS OF RECORD O 0m PLAN '`30a��� �' �� 1995 � 117 PARSLEY LANE `` (n t ��� /� ®�®� �`� OSTERVILLE. MA PROPERTY ADDRESS W SCALE: t i n = 20 f L \v/ CD 60ASSESSORS MAP 165 PARCEL 112 ± e 20 0 20 40 43 TRIANGLE CIRCLE 3 n NOTE SANDWICH MA 02563 LAND COURT PLAN 3 0 3 8 4 H Ln �j �j ` 506 364-0694 O O " o�i z N z (n ` `` 0 la 20 ! EXISTING CESSPOOL IN THE AREA OF THE DATE: J lJ N E 25. 2009 N Ln , N N I PROPOSED LEACHING GALLERY IS TO BE JOB E T E-316(0 PAGE 1 O f= 2 VERSION: O o x �' + PUMPED. COLLAPSED AND REMOVED. THIS PLAN IS BASED ON AN INSTRUMENT SURVEY AND IS INTENDED w D w ° EXCAVATE ALL ASSOCIATED CONTAMINATED SOLELY FOR INSTALLATION OF THE PROPOSED SEPTIC SYSTEM SOILS AND REPLACE WITH CLEAN MEDIUM DEPICTED HEREON. FOR ANY OTHER CHANGES TO PROPERTY INCLUDING 9 SAND PER TITLE 5. PLACEMENT OF ADDITIONS, SHEDS. FENCES OR SWIMMING POOLS. OWNER SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. DATE OF TEST: JUNE 24. 2009 SOIL TEST LOG APPROVED SOIL EVALUATOR:• DAVID D. COUGHANOWR. #461 DESIGN CALCULATIONS WITNESSED BY: DAVID STANTON. HEALTH DEPT. PERC NUMBER: 12607 ' DESIGN FLOW: 3 BEDROOMS X 110 GPD = 330 GPD ' - 1 SEPTIC TANK: 330 GPD X 2 DAYS = 660 GALLONS TEST PIT 1 PARENT UMATERIAL:ENCOUNTERED OUTWASH INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED)' PERC AT 84 in - 2 MIN/INCH IN C SOILS DISTRIBUTION BOX: USE 3 OUTLET D-BOX. ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER SOIL ABSORBTION SYSTEM: A 24 Ft- x 12.5 Ft x 2 ft LEACHING GALLERY CAN LEACH(INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING Abot = ( 24 x 12.5 I = 300 sf 51.40 A s d w = ( 24 + 24 + 12.5 + 12.5 ) x 2 = 146 sf 0-15 FILL At = 446 sf 15-18 O LOAMY SAND 10 YR 2/1 NONE FRIABLE Vt 0.74 x 446 = 330.04 GPD 18-22 A LOAMY SAND 10 YR 3/3 NONE FRIABLE USE A 24 ft. x 12.5 ft" x 2 ft GALLERY. Vt = 330.0-1 GPD > 3390 GPD REOUIRED 47.65 22-45 B LOAMY SAND 10 YR 4/6 NONE LOOSE 39.90 1 45-138 C MEDIUM SAND 10 YR 5/4 NONE LOOSE TEST PIT 2 NO GROUNDWATER ENCOUNTERED LEACHING GALLERY PARENT MATERIAL: PROGLACIAL OUTWASH USE SHOREY PRECAST 500 GALLON NOT TO 2 MIN/INCH IN C SOILS LEACHING DRYWELL lH-10 LOADING) SCALE 1500 GALLON SEPTIC TANK ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER CONSTRUCTION DETAIL DIMENSIONS AND DETAIL NOT TO (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 50.65 0-8 Ap LOAMY SAND 10 YR 2/2 NONE FRIABLE DRYWELL UNIT STON 24.0 f t USE SHOREY ST-1500-H-10 SCALE 8-36 B LOAMY SAND 10 YR 4/4 NONE LOOSE m Q 47.48 36-132 C MEDIUM SAND 10 YR 6/4 NONE LOOSE 1 In 4, TAPER 39.65 N IE§::Ilm l!l �� GROUNDWATER ADJUSTMENT DISTRIBUTION BOX �� N0 ED 0 5 FL- EXISTING GROUNDWATER LEVEL DIMENSIONS AND DETAIL USE Sl••K�?EY 08-3 H-10 8 In BASED ON TOWN OF BARNSTABLE 3.5 F B.5 f t 6.5 f t 5 �t GIS DEPARTMENT RECORDS. 24.0 Ft +•, INDICATEDtGW w5.00 NOT TO 12 in 1 r" 'INDEX WELL, M`IW-29 SCALE MIN le �k,0 ZONE- C f• f.1. ` . READING'DATE MAY 1.2009 O FROM —� 500 GALLON DRYWELL r READING 7.4 [ TANK ffr7 O DIMENSIONS AND DETAIL j ADJUSTMENT 2.3 AS S;t ; ruJADJUSTED GW 7.3 O (D yAw a a"A# USE H-10 UNIT INLET CENTER OUTLET j` ® INSTALL ONE INSPECTION END COVER END ^ 6 in STONE BASE RISER TO WITHIN THREE INCHES OF FINAL GRADE CROSS SECTION VIEW AND INDICATE LOCATION 3 IN DROP FT 4 IS.S 1 1 ON AS-BUILT PLAN —► /l FLOW LINE n FROM • � s L BUILDING.: 10 in = 14 TO In ;: D-BOX t 0 33 48 in NOTES LIQUID GAS oa��oo Boa OOOp� 1n LEVEL BAFFLE 0000a0000000 ��p 1) INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. 2) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REOUIREMENTS 5g OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). la? CROSS SECTION VIEW 3) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. CROSS SECTION VIEW 4) EXISTING CESSPOOLS TO BE PUMPED. COLLAPSED, AND FILLED OR REMOVED. 2 ki[:A PETNE 2 in PEASTONE SEWAGE DISPOSAL SYSTEM PLAN 5) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON, FINES AND DUST IN PLACE. 6) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES -TO SERVE EXISTING DWELLING AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK. 28 4,n ro 26 Z) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT InI-1/2,�GRA in JOSEPH AND SLUZANNA GOLMANAVICH PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. 46 in 58 in 46 In 117 PARSLEY LANE OSTERVILLE, MA 6) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL 150 in ECO-TECH ENVIRONMENTAL STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING. INSTALLER MAY SUBSTITUTE AN APPROVED GEOTEXTILE 43 TRIANGLE CIRCLE SANDWICH MA 02563 FABRIC IN PLACE OF THE 2 in. PEASTONE LAYER SPECIFIED. 9) SEPARATION OF TEES IN SEPTIC TANK SHALL BE NO LESS THAN LIQUID DEPTH. ETE-3160 I JUNE 25. 2009 2/2