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HomeMy WebLinkAbout0063 PINE LANE - Health '63. Pine Lane Osterville P A = 118 085 _ I I i No. Fee �® THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for 30isposaf.6pstrm Cunstrurtiun permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) KComplete System ❑Individual Components Location Address or Lot No. 4,3 Pin e i-Afic Owner's Name,Address,and Tel.No. Assessor's Map/Parcel F. G Installer's Name,Address,and Tel.No. (?.4 p �fJ6- C_,7 j� � Designer's Name,Address,and Tel.No. Z'l -77 7-7 JM•a� aa� •yYa Type of Building: Dwelling No.of Bedrooms 2 Lot Size 3 U -! r sq.ft. Garbage Grinder( ) Other Type of Building S.� rr ,,l� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) <3 gpd Design flow provided j C-) gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil �:,a,Z.. ,9)0r_N �- 4� Et _y 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 Health.11 _ Signe '/ � � Date Z - � Z ' ZG'+� Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ��� �,� �_����- - Date Issued No. / ` Fee le Q - THE COMMONWEALTH OF°MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4plitatlon for lois000 al6pstrm Construction 3pPrmit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. !v3 Pi n 2 L A yj E Owner's Name,Address,and Tel.No. osTErLvjlke Tovn C_011 �v,4,n Assessor's Map/Parcel ( ;� �5 Installers Name,Address,and Tel.No. Designer's Name,Address and Tel.No. t ' �'Q Pr cr r�E'C�1 - , Type of Building: Dwelling No.of Bedrooms 2, Lot Size 3 ooat sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 O gpd Design flow provided 33(o gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soils 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 Health. Signe Date oZ - Z Z - Zt.)-7 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued (� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by C A p ✓1'fL to at 63 Pin9 .4w 2 0 51-0- N\\-t has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No�/7-G,� dated ) Installer A per; 4�-Vl 6 S dj 5--S Designer 011 [-.A A,- r #bedrooms Approved design flow L` gpd s The issuanc of tls permit shall not be construed as a guarantee that the system9w.iii- : on as des' d. Date ��;-? i / Inspecto ' ---- --------------------- ------------------------------------------- '_.] �7 ----------------------------------Fee------------------- -Oo -/CCU THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstetn Construction Vertnit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at (0 Pi ,n,C 1.OAn e_ 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 test be co m)lej within three years of the date of this ermi.. Date / Approve . yob Town of Barnstable Regulatory Services g ! Thomas F. Geiler, Director M�tV�lA8t.8, Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862A644 Fax: 508-790-6304 Installer& Designer Certification Form Date: .3 Sewage Permits! a 0 l 7` 050 Assessor's Map\Parcel fl*lf Designer: O r F r n�.t Installer; uJ i v� ��p 0 7��•e Address: / J/ a, Address: t 53 ®cttucca�t, z Ntvu`A Nl�s �c L� AP85* 6 eIJ rW0JS6� was issued a permit to install a (date) (installer) septic system at �3 lot� &a.v�Q based on a design drawn by (address) cal 0 1A dated re-,V. 0Z l7 i7 (desi r) I certify that the septic system referenced above was installed substantially according to the desip, which may include minor approved changes such'as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with,major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & .Local regulations. 'Plan revision or certified as-built by designer to follow.. • ��tNrll Mats s. j am` 1-)ANILIAOJALA rr (rnstaller's Sign e) (:Ivn. esigner's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLF PUBLIC HEALTH DIVISION CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THF��A'ItN9TABLE PUBLIC HEALTH DIVISION THANK YOU Q:Health/SePIJUDesigncr Certification Form 3-26-04.doc r CITY/TOWN- 0�+e"Vi I APPLICANT: Dior*-old , CC.?.5-1'r4C "OO `4fC4 P?aA9 t ADD]E�ESS: ; t0 3 P�o o— L ref? e- 1 DESIGN FLOW: god / REVIEWED BY: DATE: N/A OK 1 dO .,;.., �t..,t~i• . o-4;t{a'x -v.: 'G .,sy't': -T .1 Y:7� e.... �>7�" z.s<.- ai'-Lrdt •c. ig.: i i'„>, •e t%' .:tr `•f� _-�.�,.- k'�:: <^�,Y.'i>d <.S'�:'Sti� ..cLa s;�, :?.FT+r.'•�:+::�r�-:-t.:N-a:�:; ..,ks: �4•[1...�-.` �^i�_t4sr.:k.s..,ci' Legal boundaries denoted[310 CMR 15.220(4)(a)] 1/ Street, Lot,tax parcel number and lot number noted on plan[310 / CMR 15.220(4)(u)] v Locus Provided [310 CMR 15.2204(t)] r Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for ' components) [310 CMR 15.220(4)] Easements shown [310 CMR 15.220(4)(b)] System located totally on lot served [310 CMR 15.405(1)(a) for upgrades]- if. not, a variance is required [310 CMR 15.412(4)] Location of impervious surfaces (driveways,parking areas etc.) [310 CMR 15220(4)(d)] , Location all buildings existing and proposed 310 CMR 15.220(4)(c)] Location and dimensions of system components and reserve areas. [310 CMR 15.220(4)(e)] System Calculations [310 CMR 15.220(4)(f)] ,daily flow 1 j septic tank capacity(required.and provided) soil absorption system(required and provided) ` whether system designed for garbage grinder North arrow [310 CMR 15.220(4)(g)] ' Existing and proposed contours [310 CMR 15.220(4)(g)] Location and to of deep observation holes existing grade el. on g P ( each test) [310 CMR 15.220(4)(h)] ) Names of soil evaluator and BOH representative [310 CMR / J 15.220(4)(h) and(i)] V Location and date of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(i)] Percolation test results match loading rate? [310 CMR 15.2421 e✓ f Certification statement by Soil Evaluator [310 CMR 15.220(4)0)] t� o Observed and Adjusted groundwater (method for adjustment J given or indicated) [310 CMR 15.103(3) and 310 CMR 15.220(4)(n)] z Address Sheet 1 of 7 e i i N/A ® NO i Location of every water supply,public and private, [310 CMR t 1 V E 15.220(4)(k)] within 400 feet of the proposed system location in the case of surface water supplies and gravel packed public water supply s within 250 feet of the proposed system location in the case fie' J within 150 feet of the proposed system location in the case ; [of private water supply wells ocation of all surface waters and wetlands located up to 100 ft. beyond setbacks.listed in 310 CMR 15.211 and any catch basins located within 50 ft. [310 CMR 15.220(4)(1)] i Water lines and other subsurface utilities located[310 CMR i 15.220(4)(m)] (if water line cross see 310 CMR 15.211(1)[11) i Profile of system showing invert elevations of all system components and the bottom of the SAS [310 CMR15.220(4)(0)] Stamp of designer[310 CMR 15.220(1) and 310 CMR 15.220(2)] Stamp of Registered Land Surveyor(required if construction V activities within 5 ft. of lot line) [310 CMR 15.220(3)] I Test Holes adequate(two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2) or as approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] Z Test hole adequate to demonstrate four feet of suitable material? [310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? I [310 CMR 15.103(3)] Benchmark within 50-75' of system[310 CMR 15.220(4)(q)] U/ f i Materials specifications noted? [various sections of 310 CMR 15.000] System components not>36" deep (unless Local Upgrade Approval or LUA requested) [310 CMR 15.405(1(b)] I I i I i i i I t i Sheet 2 of 7 Address I i ' t I i �+ T;3�y� �Tg.r "':;`��3.''�i 1.�°-•-}..1 2 .'rfi t 'r hTL�✓ -�,a `�' �•%� a.:atx •1''.�t rr Y �tst L `.,�,`, rs::f� y za ,�5�li�=�:et!Vr=�C� �V;Yb�:.��h �.;=�`<" a # ' s, x ns'° .�.jy, r d 8 �u.;;w..• c r �a i5 1. 'i?i'.•l�+'�i,_`'• .F i OK NO Size OK? [310 CMR 15.223(1)] Inlet tee located ten inches below flow line [310 CMR 15.227(6)] �� - Outlet tee 14" or 14" +5" per foot for uicrease ft depth[310 CMR j 15.227(6)] j Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR 15.228(1)] I Separation between inlet and outlet Lees(no less than liquid f E depth) [310 CMR 15.227(2)] Het/Outlet elevations at least 12" above high groundwater (except as described 310 CMR 15.227(5)) or permitted for upgrades under LUA[310 CMR 15.405(1)(k)] r Minimum cover 9" (Tanks buried more thad 9"must have risers j on all openings and on the d-box) [310 CMR 15.2228(1) and 310 CMR 15.232(3)(f)] Three access covers (inlet and outlet must be 20" or greater)- middle access at least 8" (by 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade - one port for systeins<1000gpd, two for systems>1000 gpd[310 CMR 15.228(2)] All at-grade covers secured to unauthorized access? [310 CMR 15.228(2)] f > 10 ft fiom building foundation [310 CMR 15.211(1)] Buoyancy calculation Required/Done [310 CMR 15.221(8)] H-20 Where appropriate? [310 CMR 15.226(3)] t Setbacks fiom resources [310 CMR 15.211] � "4•"iiY:'.'. :c:9u t%F•y�._2+5i" 'A'1•L'?7"J `r"' �:n- .r,., "amp'.. c q �r"'u:,F'a:, rt .3`f�.-?�x.2^ f r.!.�'L.i';.rt,:<•_.'6f � 1J[ul .,�.oxpax-; me� TankS � xu }' R,, > "•F< Required when other than single-family dwelling or flow>1000 f f gpd [310 CMR 15.223(1)(b)] First compartment 200% daily flow; Second compartment 100% daily flow [310 CMR 15.224(2) and(3)] "U"pipe through or over baffle, outlet of each compartment with gas baffle or approved filter[310 CMR 15.224(4)] I I! i Address Sheet 3 of 7 I N/A OK NO �{�n�4i•1�.+ r.-ti2_ ,.:x`i' ��-•• ..-�""'�3G�'e��_ •- 3^ ( -;l3`:.. ,aa. iy 9.--�p;�.s _,:_fig etisw'K::: . `P."`a' -"•`r-�."un:*.4:;f_cu I3_TIDJ[l51� (3�? ? �Z; ?._ ::.-s�.a: b,.� - Located at least ten feet fiom any water line? [310 CMR 15.222(2)] Disposal piping at least 18"below water.line(when water and i sewer cross,see 310 CMR 15.21l(1)[1]) Cleanouts required/provided? [310 CMR 15.222(8)] Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] Slope of sewer line not less than 0.01 (1/8"/fi) 0.02 preferable [310 CMR 15.222(6)] Proper pitch on all runs? (.005 w;and in gravity-distributed trenches / andbeds) [310 CMR 15.251(9) 310 CNa 15.252(2)(c)]Siphon problem/(leachfield bel pump chamber) Endcaps or vent manifold specified? Size and orientation of discharge holes specified? (not smaller / than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 �f CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) �t+"C\" air--... ,t.. -.,4 {�,•_ ;+'cra;:.:'^- '.y..;*biy� :-,..:. .:, .`*yr:. Mmpacted base [310 CMR 15.221(2) and 310 CMR)(a)] paspate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 ✓ (. CMR 15.323(3)(a)] Riser if deeper than 9" [310 CNM 15.232(3)(f)] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sump 6" [310 CMR15.232(3)(c)] Watertight cover if<2000gpd);waterproof manhole if>2000gpd / [310 CMR 15.232(3)(d)] �f REM YA '� A..k.. i Capacity(emergency storage above working=design flow)? [310 CMR 231(2)] 1 I Proper setbacks [310 CMR 15.211 (same as septic tanks)] dl ! Watertight 20-in minium access manhole at least 20"MUST BE f' TO GRADE [310 CMR 15.231(5)] Service components accessible(not too deep with piping, disconnects accessible) Alarm floats - alaim on circuit separate from pumps specified? / Exceeds two units must have two pumps operating in lead-lag V inode. [310 CMR 15.231(6) and(8)] f Stable Compacted Base[310 CMR 15.221(2)] ` Buoyancy calculations needed?Provided? [310 CMR 15.221(8)] Sheet 4 of 7 Address . I - I N/A OK ITTOOn i � r-n - _-Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1)] Required separation to groundwater? [310 CMR 15.212)] .' Aggregate specified as double washed[310 CMR 15.247(2)] System Venting required/provided? (system under ch-iveway or >36" deep)[310 CMR 15.2411. Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] Breakout requirements met? (No violation of breakout elevation i within. 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and � Guidance Document] III :r....-..5.... .._._...{...............li N.t 1.ro..,., +ii� 1 r W GAg + SYT ;C =; R5310 GIl�l1�75253A �,, '1 ^Er^ iw � ' Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] Each structure with one inspection manhole(if>2000 gpd must be to grade) [310 CMR 15.253(2)] Aggregate I'minimum-4'maximum. [310 CMR 15.253(1)(b)] 2' sidewall credit maximum[310 CMR 15.253(1)(a)] In bed configuration, inlet every 40 sq. ft. [310 CMR 15.253(6)] Width 2'minimum.3'maximum [310 CMR 15.251(1)(b)] r�; 100 feet-maximum length [310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater(3x if reserve between trenches) [310 CMR 251(1)(d)] G � I Situated along contours [310 CMR 15.251(2)] Breakout OIL? [310 CMR 15.211(1)[4] and Guidance Document] QED SA (�I4taairn' ice_ 22 of bec ,c I fiae7c 50;00 �d M- maw j minimum 2 distribution lines [310 CMR 15.252(2)(a)] . Maximum separation between lines 6' [310 CM R15.252(2)(d)] d Maximum separation between lines and outside of bed 4' [310 { CMR 15.252(2)(e)]' Aggregate depth below discharge pipes 6"minimum, 12" maximum. [310 CMR 15.252(2)(g)] ;e Separation between beds 10'minimum. [310 CMR 15.252(2)(f)] j Bottom area used in calculations only[310 CMR 15.252(2)(i)] i i i I , Address Sheet 5 of 7 N/A OK NO x ;��;��' �Y� Pressure Dosed Systein ? Provided pump and piping i calculations as required[310 CMR 15.220(4)(r)] Pressure dosing required on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and I/A Remedial Use Approvals] i if•used in gravelless system-make.sure jet is directed as not to / scour soil interface [Guidance Document] Inspections once per year(systems<2000 gpd) or quarterly (>2000gpd) good to note on plan[310 CMR 15.254(2)(d)] Construction in fall -Did the plan specify that the fill shall meet V I the specification of 310 CMR 15.255(3)? ! Impervious barrier and/or retaining wall? [Guidance Document] / Impervious barrier installationmust be supervised by designer[310 CNIR 15.255(2)(b)] Retami mi g wall roust be designed by Registered Professional J t Engineer [310 CNIR 15.255(2)(a)] Side slope not exceed 3:1 ? [310 CMR 15.255(2)] Breakout requirements met? [310 CMR 15.252(2) and Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. } recommended) [310 CMR 15.255 (2)(e)] _ Check DEP Approval letters for credits and design conditions . If used with pressure dosing do not allow pressure discharge •' to scour soil interface � .t4 �.u r-yea: ry TM =�.ate ._rOgl g,4 ff P c Sys elr, fl/ AP ovrcl '; tea : Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? - Is the technology being properly applied and does it meet all DEP Approval Conditions? Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a copy of a maintenance Are the variances listed on the plan? [310 CMR 15.220 (4)(q)] RLS Stamp necessary on plan if a component is within five J feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed- [Refer to 310 CMR. 15.414] Sheet 6 of 7 Address . k 1 N/A. OK NO K Is the system in a Designated Nitrogen Sensitive.Area(Zone 11 for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 - also.refer to Policy regarding upgrades of such •' existing systems] Is the system proposed on the same lot as served by private well ? [310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CT AR 15.216(1)] - - . g Pumping to septic tank? [310 CMR 15.229] �!f/ Shared System[310 CMR 15.290] i I f I; 1 Address Sheet 7 of 7 I • ooawZroao�rgdv��s�=2� °2uplugaq o;xopd 49oA&(T)axro May p uoppLyC paoY.pAlasnmo3 algv;s ff br .ot pxg jsxa=nag apax aA&jo c00j uMTA&popupa m aq c•sl jsaj ago Wgoo xad(R,,,' -- --- g uo pMoldrudZ)ag 6j,Utz Clog uopauesgp nols ATQ gjMH ongna :TIIIII�I r0 (hUX�papaaml uvs4l I PIPAd mailu3`d715 passe allS anatassacsy,�jTTTq�TnS oIIS 3ruos-wi 749 - ---Y� y ,- (rr9-r,5}s.+� .. 0®nn.S.31Vgs-O•Id7Te]S i� •—Y---••--'•� �/ rtb�'��1�- yr ,�•� y7�ry,�y�p• �.-p,. rye uo>a>;,uas40 • r.Y:i�,n,u.l�l.l'-"V:LiJrS .Loi.Jwm """'1aAa`1aa7u�hpuittxtE) I CE' MM'W `"'""y�.Iuhnb TIC&=PUI -IpQ 2WPOU #IIaM=PnI 1 ._ DII�TUJ7rj wY Tq amp=WD .lq %qoq•sqo p opts mag S.t rd=A zn tp&a 'ul ;=apsw libra ttlacr- ,aI :aloq*sqo rtl;3m pugs pa uasg0 rPdaQ :pasnpatmAx . - :_ xa7Erapunarp�I�TH TEnosea.Spa�'eiuPsS ' T_H a o koo •e�b2 )ptupag mdoa )V71ri1 � � (oT�oloa IUFM=7u=a . (salon oX�nuncozd�spuEpaM a�gol�sasa;omd�g s�s�saa;o suot�aaal aasxa Jti13o s[tols¢atuTP'aruUu 7aags7 5�r�r'i s�5 �ag70 v au1lAxadoia y TIaIx1Ja]nM$ In1�Q (J uwioMaT4Tssod. -u--(jr, —Apogia1aMumdp :ma vamia (96)ssdoCS i'J A w lid :asri PM7 S #'IID�d^'Ia•L �o'da2T Y xo=nmshTOO Am Qm III • II� ��Q���/. •JOIE�fEj/�1.5�71t]SSOS6'� . ssaipP b': :x h~�� Rftw`cf uoi7�aa7 .L, :9'GIl . .l :dg passaIIat� . ^ �� / :,Cg patty�aa LO ,Pa a , palnpa,Ipg apQcv .. login rdN slIInd1l'aaang rgvw On ssyss . Uneaset�z, l . • to.� • pa �- �q w O •�, • F+� 0 8, � o n. w o to qua ern o y o o 7as mp i� a G ? .p V3 ❑ o .tl o qj O Td v v U v t7 fl7 CD a3 hp ® td �8 9 0 `�� _ 0.0 CD Da cc tri n3 14 . -10 dNZ A a o v .-� Irr 'A u 4 Ej , ° o • y �Cc' �J V - Pei rn � � � to /�•� � �•7�./�_ O +'� cd � •• ' to • �J' o o ,� O g m AN O 0 34 '9aiFBI 3 'gyp � t� O m O o 13 o � ta c� ME oin n W o u, O fta � + TOWN OF BARNSTABLE LOCATION (o3 Plmei &AA J SEWAGE# �U1"l '®S® ,VILLAGE ASSESSOR'S MAP&PARCEL 1 I8 & S INSTALLER'S NAME&PHONE NO.Ce4PCL0Lt g -:: t E 411 SEPTIC TANK CAPACITY 1500 o � LEACHING FACILITY. (type 5CQr,-L C84AK43 (size) X 3® NO.OF BEDROOMS OWNER 6TKoA4*S CUWAJAw PERN4IT DATE: 20t COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Ai/4 Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) 1�1#4 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Maw1 De E0J WgiSCS .. _ ZA - U o N q q �+ CP r w Q C 5 S g � 't1 ^i (� cn p �,,, TOWN OF BARNSTABLE LOCATION QlME. e A�JJ5- SEWAGE# )�O1l -OSO VILLAGE i ASSESSOR'S MAP&PARCEL I$ S INSTALLER'S NAME&PHONE NO.G4?66XNE ��3T�2►?/ 4�7$ Z� SEPTIC TANK CAPACITYLEACHING FACILITY:FACILITY:(typeX�)$COJA.t, CkAe (size) 9.931 X 60 j NO.OF BEDROOMS OWNER THOK,k C-0gimA41 PERMIT DATE: ,2- - ;uj(1 COMPLIANCE DATE: a'a--!'.Z.O 17 Separation Distance Between the: i Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility AJ A Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within j 300 feet of leaching facility) i 0o'c Feet FURNISHED BY AAFewi 045 6 l FR gjsES I A -I S.5 ' f A-2 ; iS FRMr P A-3 - c e A-4 -1 Z( d A-5- 2�.S ' © o L 3 B-1 - 14.I' C-1 - 34 ` 4 Q-Z is C-2- 28 ' ri Q-3. 21.5 C- 3 = 3s ' O-q= 24.S` C-4= 37-S ' S • f` TOWN OF BARNSTABLE 3 44 J..t:f : N � � t f �� SEWAGE # �►T10 1 f:sLLAGE Mryi lul ASSESSOR'S MAP & LOT tll ' OFT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY C.2.SS GO�S LEACHING FACILITY: (type) �,<S�IGb� •�' (size) NO. OF BEDROOMS 0-- BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Wattr Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachip g.facility)--�— Feet Furnished by„�/t WLX, a-� y • �0�� Aa- a L Q3, a3 3 �Y� 33 CY- 3y Cl. Y COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION �f ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 �f j04 F ' 1 �ov 8 4*DY COXE p S fret cY ARGEO PAUL CELLUCCI S' DAV �STRUHS Governor e Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 63 Pine Lane, Osterville, MA Name of Owner: Jerry Sutelman Address of Owner: P.O. Box 95 Date of Inspection: July 10, 2000 IFesnvood, MA 02090 Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M. Ford Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map: 118 Telephone Number: (SM)862-9400 Parcel: 085 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes _ Conditionally Passes Needs Further Uvaln By the Local Approving Authority \Faiilsls Inspector's Signature: I Date: July 12, 2000 The System Inspector shall subf copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page 1of11 Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 63 Pine Lane, Ostendlle, MA Owner: Jerry Sutelman Date of Inspection: July 10, 2000 INSPECTION SUMMARY: Check A, B, C, or D: y A. SYSTEM PASSES: ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If."not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as I' approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health) broken pipe(s)are replaced _ obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 63 Pine Lane, OsteMlle, MA Owner: Jerry Sutelman Date of Inspection: July 10, 2000 C. FURTHER EVALUATION IS REQUIRED BY THE. BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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. Method used to determine distance (approidmation not valid). 3) OTHER , a revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 63 Pine Lane, OsteMlle, MA Owner: Jerry Sutelman Date of Inspection: July 10, 2000 D. SYSTEM FAILS: You must indicate either"Yes" or"No" as to each of the following: _ I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow. 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 63 Pine Lane, Ostervllle, MA Owner: Jerry Sutebnan Date of Inspection: July 10, 2000 + wi have been done: You must indicate either"Yes" or"No" as to each of the following: ' Check�f the following g i Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health. *✓ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. (*Weekend use.) n/a As built plans have been obtained and examined. Note if they are not available with N/A. ✓ _ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout.' ✓ _ All system components,excluding the Soil Absorption System,have been located on the site. ✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: ✓ Existing information. For example,Plan at B.O.H. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)l• ✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 63 Pine Lane, Ostendlle, MA Owner: Jerry Sutelman Date of Inspection: July 10, 2000 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): n/a Number of bedrooms(actual): 2 Total DESIGN flow n/a Number of current residents: 0 Garbage grinder(yes or no): Yes Laundry(separate system)(yes or no):No If yes, separate inspection required Laundry system inspected(yes or no): Yes Seasonal use(yes or no): No Water meter readings, if available(last two year's usage(gpd): 1999-34,000 gals.: 1998-42.000 gals. Sump Pump(yes or no): No Last date of occupancy: Weekend use COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: ead(Based on 15.203) Basis of design flow Grease trap present: (yes or no) Industrial Waste Holding Tank present: (yes or no) _ Non-sanitary waste discharged to the Title 5 system: (yes or no) _ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: None on file-per treatment plant. System pumped as part of inspection(yes or no): No If yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool 2 Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information: Unknown Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 63 Pine Lane, Osterwile, MA Owner: Jerry Sutelman Date of Inspection: July 10, 2000 " BUILDING SEWER: _ (Locate on site plan) - f Depth below grade: Material of construction: _cast iron _40 PVC _other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: None (locate on site plan) ` Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: s u { Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) GREASE TRAP: None (locate on site plan) Depth below grade: ; Material of construction: _concrete _metal Fiberglass _Polyethylene _other(explain) Dimensions: F 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: y Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 63 Pine Lane, Osterville, MA Owner: Jerry Sutelman Date of Inspection: July 10, 2000 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present: Alarm level: Alarm in working order: Yes_ No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX: None (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER: None (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order: (Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 63 Pine Lane, Osterville, MA Owner: Jerry Sutelman Date.of Inspection: July 10, 2000 ` SYSTEM NI ` SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if,possible.;excavation not required, location may be approximated by non-intrusive methods) If not located,explain: Type: r leaching pits,number: leaching chambers, number: leaching galleries,number: leaching trenches, number, length: leaching fields,number,dimensions: overflow cesspool,number: 1 Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.) , The over cesspool was S'Wx 6'6"Tx 10'6"bottom to grade and was dry. The scum line was]'up from the bottom. There was root growth in the overflow cesspool. There were no signs of failure. The cover was 3'6"below grade. CESSPOOLS: ✓ (locate on site plan) Number and configuration: I with overflow Depth-top of liquid to inlet invert: S" Depth of solids layer: 3" Depth of scum layer: 1" Dimensions of cesspool:S'W x 4'Tx 76" bottom to grade Materials of construction: Block Indication of groundwater: None inflow(cesspool must be pumped as part of inspection). Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.) The liquid in the cesspool was up to the outlet pipe. There was root growth in the cesspool. The cover was 18"below grade. The bathrooms go to this system. PRIVY: None (locate on site plan) Y Materials of construction: = Dimensions: Depth of solids: Comments: ' (note condition of soil, signs of hydraulic failure,,levefof ponding,condition of vegetation,etc.) revised 9/2/98 Page 9 of 11(System#1) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 63 Pine Lane, Osterville, MA Owner: Jerry Sutelman Date of Inspection: July 10, 2000 SYSTEM#2 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number: I-6'x 6' leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number,dimensions: overflow cesspool,number: I Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.) The nit was dry The scum line was 1'up from the bottom There were no signs of failure. The bottom to grade was 9'. CESSPOOLS: ✓ (locate on site plan) Number and configuration: 1 with overflow Depth-top of liquid to inlet invert: 15" Depth of solids layer: 3" Depth of scum layer: 1" Dimensions of cesspool: 3'W x 3'Tx 6'bottom to grade Materials of construction: Block Indication of groundwater: None inflow(cesspool must be pumped as part of inspection). Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.) The cesspool had 2'of water on the bottom The kitchen goes to this system PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.) revised 9/2/9 8 Page 9 df 11(System#2) j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 63 Pine Lane, Ostemlle, MA Owner: Jerry Sutelman Date of Inspection: July 10, 2000 = , Map: 118 Parcel: 085 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) I nT STenn o� s S`f "M \ AI 11 � O • Q yr - aa- aa- ay 33- C3- lay- 33' Cy revised 9/2/98 Page 10of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART C SYSTEM INFORMATION (continued) Property Address: 63 Pine Lane, Osterville, MA Owner: Jerry Sutelman Date of Inspection: July 10, 2000 NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property,observation hole, basement sump etc.) ✓ Determined from local conditions ✓ Checked with local Board of Health Checked FEMA Maps Checked pumping records Check local excavators, installers ✓ Used USGS Data Describe how you established the:High Groundwater,Elevation.: ust be completed) The bottom of the overflow cesspool to grade was 10'6". Using the Barnstable topographic map and water contours map, the maps were showing approximately 37' +/-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. revised 9/2/98 Page 11of11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL P7RE N-- EIVED 2 2 2003 F BARNSTABLE LTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 63 Pine Lane MAP � 1 Osterville, MA 02655 PARCEL Owner's Name: Jerry Suletman ...,... Owner's Address: LOT ' Date of Inspection: August 30, 2003 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Map: 118 Mailing Address: P.O. Box 49 Parcel:085 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes N, Further Evaluation by the Local Approving Authority Fa' s Inspector's Signature: Date: September 4, 2003 The system inspector shall su t 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 63 Pine Lane Osterville, MA Owner: Jerry Suletman Date of Inspection: August 30, 2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y;N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 63 Pine Lane Osterville, MA Owner: Jerry Suletman Date of Inspection: August 30, 2003 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 63 Pine Lane Osterville, MA Owner: Jerry Suletman Date of Inspection: August 30, 2003 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow _ ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is.equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of.10,000 gpd to 15,000 gpd• You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered`yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office.of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 63 Pine Lane Osterville. AM. Owner: Jerry Suletman Date of Inspection: Au-awt 30, 2003 Check if the following have been done: You must indicate`yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? n/a 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? m ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 63 Pine Lane Osterville, MA Owner: Jerry Suletman Date of Inspection: August 30, 2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 0 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): pd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: None on file-per treatment plant Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool 2 Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 63 Pine Lane Osterville, MA Owner: Jerry Suletman Date of]inspection: August 30, 2003 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,.etc.): SEPTIC TANK: None . (locate on site plan) , Depth below grade: Material of construction: concrete _metal fiberglass _polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: . Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or*baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t SYSTEM INFORMATION(continued) Property Address: 63 Pine Zane Osterville. MA, Owner: Jerry Suletman Date of Inspection: August 30, 2003 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): r 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 63 Pine Lane Osterville, MA Owner: Jerry Suletman Date of Inspection: August 30, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓. (locate on site plan,excavation not required) If SAS not located explain why: Type SYSTEM#1 leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: ✓ overflow cesspool,number: 1 Innovativelalternative system Type/name of technology: Comments:(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The overflow cesspool was S'Wx 6'6"Tx 10'6"bottom to grade and was dry. There was root growth in the overflow. There did not appear to be any signs offailure. The cover was 3'6"below grade. CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: I -with overflow Depth-top of liquid to inlet invert: Even Depth of solids layer: S" Depth of scum layer: I" Dimensior_s of cesspool: S'W x 4'T x 7'6"bottom to grade Materials of construction: Cesspool block - Indication of groundwater inflow(yes or no): No Comments, (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): The lipuie in the cesspool was up to the outlet pipe. The cover was 18"below grade. Recommend pumping and pumping every two years,for maintenance. Bathrooms flow to this system. PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 63 Pine Lane Osterville, MA Owner: Jerry Suletman Date of Inspection: August 30, 2003 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: E Type SYSTEM#2 ✓ leaching pits,number: 1-6'x 6'(1000 gall leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): The pit was dry. The scum line was approximately Pup from the bottom. There did not appear to be any signs of failure. The bottom to grade was 9'. The cover was 2'below grade. CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 1 with overflow Depth-top of liquid to inlet invert: Depth of solids layer: 6" Depth of scum layer: -- Dimensions of cesspool: 3'W x 3'T x 6'bottom to grade Materials of construction: Cesspool block Indication of groundwater inflow(yes or no): No Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): The cesspool was dry. The kitchen flows to this system. The cover was 16"below grade. PRIVY: None (locate on site plan) i Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9a Page 10 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 63 Pine Lane Osterville, MA Owner: Jerry Suletman Date of Inspection: August 30, 2003 Map: 118 Parcel: 085 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. - .._._..... — ..-...__ S�suob. d� Alm r3a� ay A �` Q3• a3 � 3 �Y� 33 C a Y 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: 63 Pine Lane Osterville, AM Owner: Jerry Suletman Date of Inspection: August 30, 2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 37+/- feet Please indicate (check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using the Barnstable topographic map and Cape Cod Commission water contours map, the maps were showing approximately 37'+/-to ground water at this site. r This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. 11 THE C® �AON®ALTHCOFMA�SS;CH SETTS B .... OF................ ....... ` .......................... Appliration for Diii uial Works Towitrurtion Puntit Application is hereby made for a Permit to Construct ( ) or Repair ( t-tr an Individual Sewage Disposal System at , ---....-. .. •- . ........ •-•-••••••-_---...----•-----.-•----•..............•-•..--.•.--•----••-•-•-•-••----....--.----_-__ Locat' -Ad or or Lot No. . Address ...... Installer Address ype of Building Size Lot............................Sq. feet �-, Dwelling o. of Bedrooms_-----------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures ----------------------------------------------------- Design Flow............................................gallons per person per day. Total daily flow----------------------------------.---------gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width-----..__.__._.. Diameter---------------- Depth_-------------- x Disposal Trench—No- --------------------- Width.................... Total Length_-____--_---..._--_- Total leaching area.._-._._-_-_-.--__-_sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area._.._.___.-_---_sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY.......................................................................... Date--------------------------------------.. Test Pit No. I----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water._._--__-_-__-_-__------ G� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.._-_._..-__--.__-_-.... Description of Soil__._-_- ---__-- ................... x U ---------------------------- - ---------------------------•_.------------------------------------------------------------...----------------------------------------- UW / -- -- - -------- - Nature of Rep ' Alterations—Answer when applicable. . 7�---••-. / � ---- ...-- -- ------------------------------------------------------------------------------------------------------------------------------------- ---------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary C e— The undersi ed further agree not to place the system in operation until a Certificate of Compliance has been _sued by oar e h. Signed-- --- - --- ------------ -o- - - - ---- .-•- - - ---'. Date Application Approved B Date Application Disapproved for the following reasons:------------------------------•-••-------------•-----•-----------------------•----------------•----.------------ ---------------------------------------------------------------------------------------------------------.------. --------------------------------------- ----------------------------------------------- Date Permit No. Issued 7...,............. Date THE COMMONWEALTH OF MASSACHUSETTS Application is hereby ma e for a Permit to Construct or Repair.'...( ean Individual Sewage,.Disposai" SyUe%at: Address Other Distribution box Dosing tank P4 O Description c6S�J'' -__--___-'-.-------_----'-----.--_--' -_.-------_--'''_-' -_- '''`..................................................... - � ---------------- - ----------------------------------------------------- - Nat4j:e Alterations—Answer when applicable------- od........ -0 �P_ Agrecmcot: � The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article Xlof place the system in o peotimu until uCertificate of Signed. ...'--........ .............-....--v' ...................--'��--- ---_-���-_--- ApplicationApproved By................................................................................................... -----------.-.-. � "=" Application Disapproved for the following reasons�................................................................................................................. � _—_--_--''----�.---._-_------'--__----------.--._--'-_----'_-_---.-_-_._---.-_ . Date PermitNo......................................................... Date . ' . THE oomMowvvsALr* OF MAssAo*uesrrS � BOARD HEALT | � ' '.. 0F....��� ----- � ` 'I taller has been installed in accordance with the provisions of Article XI of The State Sanitar C� e s -Construction Permit No. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE COMR.UED A"- GUARANTEE THAT THE D&T In or | «'y ' ' '^~ ~, ' THE oomwomvvsALr* OF mAssAc*uesTrs ' - � BOA � � �� � rr:Xe n, ndivi� ...........C � pplication for Disposal Works Construction P N � ~~ �"=" m � h`. ........ °mm � ice �'s*c�� ' ALL STE SYSTEM PROFILE MAR ED WITHCMAG4ETICTTAPEAOR BE NOTES (NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. PROVIDE MIN. 20" DIAM. WATERTIGHT 1. DATUM IS NAVD 88 B'h ' ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE s Ri�e� Ro 2" PEASTONE OR GEOTEXTILE 2. MUNICIPAL WATER IS EXISTING \ TOP FOUND. EL. 41.6' 40.0 FILTER FABRIC OVER STONE 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQURED OVER SYSTEM a NOTE: 2" MIN. WALL MORTAR ALL 4. DESIGN LOADING FOR ALL PROPOSED PRECAST o �� PRECAST H-10 THICKNESS REQUIRED BLOCKS OR (�,1 COMPONENTS UNITS TO BE AASHO H—]Q * RISERS �.P PRECAST RISERS 39.0' 6" MIN. SUMP 4">�SCH40 PVC ( ) H-10 oc :... %E -� 12" MIN. INT. DIM. PIPES LEVEL 1ST 2' �4, j — 5' 2.5, 5. PIPE JOINTS TO BE MADE WATERTIGHT.ENDS BET• SIDES 37.03' 10" 1500 GAL H-10 Poo oo� aoa000xo6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE*38.0 36.82' TEE SEPTIC TANK \33 6.57' ° ° ° ° �a0�0 �I]00 °�� ��� 0 —PPDO '°0.°°°°° WITH 310 CMR 15.000 (TITLE 5.) e 0� > o 0 0 0 0 0 o 0 0 o I °°°°°°°° oa�0000�o�a aa�aoa000a >°°°°°° °O°O°O00°O°O '0°°O°O°O oo°o°o O O O O O O O O O >0000000o LOCO GAS BAFFLE::; ° °00 ° ° ° ° ° aooa�1o�oa000 O�D���O�O� 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND O O O O O O o ° ° ° o 0 0 0 0 0 '_OO°P'^°^°_ " �°o°o°o°o ®I�®aal�l�al�al� 0Oo°o° — — — — — O — — ,0000000o cp ~ °°°°°°°° °°°°°° �OQ����O�� :°g°o°o°o NOT TO BE USED FOR LOT LINE STAKING OR ANY CS, �P °°°°°°°° °°°°°° °°°0°°°° 34.2 OTHER PURPOSE. 4 LIQ. LEVEL (ACME OR EQUAL) 36.47 36.30 ° South o N ' ' `4 : : : :• 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. M St J000000000000000000000060000000000000000000�OL °00^0000 0,°,0,°,0°,o°,on0000000�o,°o�o,°o�0°,0,0. 000° H-10 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. N 3/4"-1-1/2" DOUBLE WASHED STONE 4' MIN. (2� UNITS REQUIRED ALL AROUND PRECAST STRUCTURES 9. COMPONENTS NOT TO BE BACKFILLEO OR CONCEALED WITHOUT INSPECTION BY BOARD OF 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 30.00'-X 9.83' HEALTH AND PERMISSION OBTAINED FROM BOARD 5 COMPACTION. (15.221 [2]) N est o0 vi OF HEALTH. o 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING DIGSAFE (1-888-344-7233) AND 29.0' BOTTOM TH-2 VERIFYING THE LOCATION OF ALL UNDERGROUND & LOCUS MAP ( 2.5% SLOPE MIN.) ( 2•5% SLOPE) ( 1 % SLOPE) NO GROUNDWATER FOUND OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF WORK. SCALE 1"=2000't 11. ANY UNSUITABLE MATERIAL ENCOUNTERED FOUNDATION_ 46� SEPTIC TANK 4' D' BOX 12' LEACHING FACILITY SHALL BE REMOVED 5' BENEATH AND AROUND THE ASSESSORS MAP 118 PARCEL 85 PROPOSED LEACHING FACILITY. *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL LOCUS IS WITHIN ZONE II UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 12. EXISTING LEACHING FACILITY SHALL BE PUMPED TWO BEDROOM DEED RESTRICTION REQUIRED PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM AND REMOVED OR PUMPED AND FILLED WITH CLEAN LEGEND SAND. 99— EXISTING CONTOUR VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY X 99•1 EXIST. SPOT ELEV. BE IMMEDIATELY GRANTED BY THE BOARD OF SYSTEM DESIGN. HEALTH AGENT OR BY HEALTH INSPECTOR —[99]— PROPOSED CONTOUR PAPERWORK AND HEARING REDUCTION PROPOSALS 19$•41 PROPOSED SPOT EL. APPROVED BY THE BOARD OF HEALTH REVISED ^ GARBAGE DISPOSER IS NOT ALLOWED DURING A PUBLIC HEARING HELD ON DEC. 10, 2013 Y TH1 1) ALL SYSTEMS THAT HAVE NO INCREASE IN S A•lvl� EXISTING 2 BEDROOM DWELLING TEST HOLE FLOW — SEPTIC SYSTEM COMPONENT TO TWO BEDROOM DEED RESTRICTION REQUIRED FOUNDATION SETBACK (NO MORE THAN 50% 1 / DESIGN FLOW: 2 BEDROOMS @ 110 GPD = 220 GPD 2� SLOPE OF GROUND REDUCTION IN REQUIRED SEPARATION DISTANCE) USE A 220 GPD DESIGN FLOW �) UTILITY POLE (20' TO 12.8') 12 / 4) FAILED SYSTEMS ONLY- SEPTIC TANK OR PUMP SEPTIC TANK: 220 GPD (2) = 440 FIRE HYDRANT CHAMBER PROPOSED TO BE LOCATED LESS THAN �8 _v o--_ - �� NOTE NOT ALL SYMBOLS MAY APPEAR IN DRAWING 100 FEET BUT MORE THAN 75 FEET AWAY FROM —�" USE A 15U0 GAL. SEPTIC TANK WETLANDS OR A WATER.. COURSE (100' TO 94.6') 24 LEACHING: 3,7 26 SIDES: 2 (30 + 9.83) 2 (.74) = 118 GPD TEST HOLE LOGS BOTTOM 30 x 9.83 (.74) = 218 GPD 28 CRAIG J. FERRARI, SE #13871 o TOTAL: 454 S.F. 336 GPD . ENGINEER: 33 WITNESS: DAVID W. STANTON RS pp�\4 6, USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) DATE: 12/21/2016 33 BENCHMARK: WITH 2.5' STONE AT SIDES, 4' AT ENDS AND 5' 34 BASIN ELEVATION PERC. RATE _ < 2 MIN/INCH 35 pPVE� =24.9 NAVD88 BETWEEN UNITS CLASS I SOILS P# 15230 36 3� pC� �R\'JE I I ELEV. I I ELEV. 39 SELL\NG APPROVED DATE BOARD OF HEALTH MA Opp4 40.5' p„ 4 40' 4o EX\SpA � g 35 FI LL FI LL _> 6 12 17" " �o 37 TITLE 5 SITE PLAN LS LS ,� °tiF OF 10YR 4/2 10YR 4/2 C/0 (TYP ;� �, H 2110 18" ; �, 12 a 38 #63 PINE LANE B B H OSTERVILLE, MA LS LS ,� 10YR 58 SLEEVE SEWER LO ��_i PREPARED FOR 42" 10YR 5/8 37' 36" / 37' LINE WHEN 10,8 5 SFf gk- WITHIN 10' OF PROVIDE 30' OF 40 MIL CULLINAN WATER SERVICE LINER AT 5' OFF SAS IN C`� U AREA SHOWN. TOP AT ELEV. C C ° 7.0', BOTTOM AT EL. 33.0't DATE: DECEMBER 30, 2016 PERC Vj V, _ ss ofM451 REV: FEBRUARY 17, 2017 (NAME) g M S DANI LA. o DANIEL �\ MS OJA off 508-362-4541 _ A 3 1-(f� fax 508-362-9880 CIVIL No. 46502 downcape.com 1OYR 7/4 1OYR 7/4 �0A41�/s1 ����r �O�o�ss��C`. � . do wn cape engineering, iac. 132" 29.5' 132" 29' S�oNn su ` civil engineers land surveyors NO GROUNDWATER ENCOUNTERED Scale: 1 = 20 ���'�-\� .�../� 939 Main Street ( Rte 6A) YARMOUTHPORT MA 02675 DCE # 16-406 0 10 20 30 40 50 FEET DATE DANIEL A. OJALA, P.E., P.L.S. 16-406