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HomeMy WebLinkAbout0163 PINELEIGH PATH - Health 163 PINELEIGH PATH, OSTERVILLE A=071-001.007 I f i r II Doi - oo--� c°,�� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Pineleigh Pass V Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. . Important:when A. Inspector Information . ��.� . filling out forms on the computer, Daniel Hawkins 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 Q Company Address Sandwich Ma 02563 City/Town State Zip Code rmu (508)477-0653 S114324 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. 0 Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Dan Hawt `..Digitally signed by Dan Hawkins 1� ,<-Date:zozo.oz.n ogas:aa-oa.00. lns 7-16-2020 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. R r t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18_ . c Commonwealth of Massachusetts " Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Pineleigh Pass _._..,.,.... Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 required for every 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 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I Commonwealth of Massachusetts �d Title 5 Offici-al .Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Pineleigh Pass Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 required for every 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): I! ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: -. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts ,p Title 5 Official inspection Form iy Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Pineleigh Pass Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 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: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form �= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Pineleigh Pass v� Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 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 ❑ 0 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 ❑ Fxl Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ a Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Q Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑. ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ E 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. s . 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No . ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El El Area 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 18 Commonwealth of Massachusetts Title 5 Official Inspection Form += Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Pineleigh Pass Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 required for every 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 all inspections: Yes No ❑ El Pumping information was provided by the owner, occupant, or Board of Health ❑ E Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ a Have large volumes of water been introduced to the system recently or as part of this inspection? Q ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? lil ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ 0 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: El ❑ Existing information. For example, a plan at the Board of Health. ❑ a Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5ins .doc•rev.7/26/2018 p Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Pineleigh Pass Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 4 3 Number of bedrooms(design): Number of bedrooms(actual): - DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440/GPD Description: x • 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? - ❑ Yes 0 No Seasonal use? ❑ Yes [E No See below Water meter readings, if available(last 2 years usage (gpd)): Y Detail 2019- 25,000gallons 2018- 24,000gallons 9 - Sump pump? ❑ Yes 9 No current Last date of.occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � r Subsurface . .._.._._. . , ... ...__ _.. Sewage Disposal System Form -Not for Voluntary Assessments 163 Pineleigh Pass V� Property Address Garratt Gillespie Owner Owners Name information is Osterville Ma 02655 7-16-2020 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- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: II n ga o s How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 t Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Pineleigh Pass Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El 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: 1998 per plans Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 2'8" 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.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18' y c � Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments77 4; 163 Pineleigh Pass Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2011 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 2000gallons - Dimensions: I 4" Sludge depth: 3211 Distance from top of sludge to bottom of outlet tee or baffle 411 Scum thickness 6„ Distance from top of scum to top of outlet tee or baffle 1311 Distance from bottom of scum to 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 in need of pumping at this time and should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form 15 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............. / 163 Pineleigh Pass u Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 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): w i Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): • I 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: a gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18' c � Commonwealth of Massachusetts Title 5 Official Inspection Form �= I.I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V � 163 Pineleigh Pass Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 , 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): o„ 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts +m ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Pineleigh Pass u Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA f * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: 8 infiltrators in line E leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5ins,p.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 r c Commonwealth of Massachusetts h Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Pineleigh Pass u— Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 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 SAS was in working order at the time of inspection. Leaching has 2" of standing water when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 cye, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Pineleigh Pass Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.); 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs;of hydraulic failure, level of ponding, condition of vegetation, etc.): t ~^- l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 ~ r Commonwealth of Massachusetts Title 5 Official Inspection Form �= to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 163 Pineleigh Pass Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ■❑ hand-sketch in the area below ❑ drawing attached separately C. TOWN OF BARNST'ABLE LOCAMON INSTALLEWS"NAME 4 PHONE.NO., sEMC TANK CApACM d=Ci l L ACHING FACIC.17 :(type) x :L_12t 'r S fsizc) 3 x f 1 No.OFiBEDRt�UAIS $vzi l�>�c erlliE Gallr . PERMTr LATE: .4-ar rc�Mt? ns�r :r�nTE ? f r Sepat doff Distance Between the: Maxitnum Adjusted Grottndwutei Table Lo the Bottnin of r eaehing Facil ty t Private want Suppiy Wall aad l aachirig•Faratity:'(If any w,ells'esisc: on sift oY within 2[1C}f�eit oE,Ieaching faci2"sty}' Feet. Edge of wetland and Leaching Facility`(Tf"any'wedainds exist within 300 f Uacbing fees ty) Feet Furnished.by +�f G, // A91 Z. A , Ey't, I sT. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 I c Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Pineleigh Pass Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ■❑ Check Slope ■❑ Surface water ■❑ Check cellar ❑■ Shallow wells No GW @ 126" Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record ' 1-9-1998 If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) El Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file at the local Board of Health was used to determine high groundwater. r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rey.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 f c Commonwealth of Massachusetts Title 5 Official Inspection Form _ " Subsurface Sewage Disposal System Form Not for Voluntary Assessments ��/� 163 Pineleigh Pass » .•• ._ u Property Address Garratt Gillespie Owner Owner's Name information is Osterville Ma 02655 7-16-2020 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 FW 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 No. -...,0 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, IA SACHUSETTS ZippYication for Miopozar *pztem Con!tru ion Permit Application for a Permit to Construct(X)Repair( )Upgrade( )Abandon( ) %Complete System ❑Individual Components Location Address or Lot No. 14 3 Pint Ici5h P&44,t Owner's Name,Address and Tel.No. 6vs is- Or G. G o fie-S r- Assessor's Map/Parcel I(0 3 Pycnel (n Pa 4f� 6�s F[r f-(c..-Loss Installer's/Name,Address,and Tel.No. t � Designer's Name,Address and Tel.No. 4 Zg'-!/.3/ V 0 0 13c xitr i MtSc T-nc. 7 7/`� d Z winch 5 MA &S Type of Building: Dwelling No.of Bedrooms F-our- Lot Size AC.557 sq. ft. Garbage Grinder( ✓S Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 44,45 gallons per day. Calculated daily flow gallons. Plan Date i IgITY Number of sheets Revision Date Title S 9 Vr A*..: A I to 3 6 Ae,i e 4 U Q-4-6 Size of Septic Tank ?,Qun cs 1"S Type of S.A.S. Ga//ey Description of Soil ®-Z4" Laam y Subsall 24"— I2f" cle..,% ymejtvw1 Q 4?- 7333 `' _If+1,29 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: �f Agreement: r The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- t cate of Compliance has been issued by . Signed Date Application Approved by Date Z Application Disapproved for the following reasons Permit No. Date Issued `'� F f� 1 ` � c� ,} No. Fee 4� P x THE COMMOWWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -. TOWN OF BARNSTABLE., M SACHUSETTS ' Zipplicatioti fortoaY € ptetn col; tru onfernYtt Application for a Permit to Construct(X)Repair( )Upgrade( )Abandon( ) X Complete System ❑Individual Components' '`Location Address or Lot No. 1(,3 Pm c le i'k Pu.441 Owner's Name,Address and Tel.No. �, °�; _ d.�sFtr Harb®rs ,.,•-• dr .�i.wDv' G. C'�I(esp�'e, Assessor's Map/Parcel ,/ �/ /'� Y; ;. f(03 eir%elti5tn 1P&K , Qlsft,- F{ar lbors `' r ice. Installer's/Name;A/ddress,and[Tee�ll..No. G Designer's Name,Address and Tel.No. Zff �avDl'/ `� i/`i t f t '1w�?, .l'Cr 1 C) (65.S - Type of Building: -rf 1,0wellings. Np of$edrddm's A E-h;w4 Lot Size SS :"ft. 6' GarKa1ge nntie' ✓S i �-Other Type of Building a t No:o f Perspn ", Showers( ) Cafeteria(tl ) Other Fixtures y � (�( _• 9 �+ _ j f7 t" "�'.rY.`�.:.�'.. 'S i° d 7"rj�l'rt ,1.✓CY,v;• A Design Flow 4 gallons per day. alculatedzlaily flow '� gallons. l *Elan Date I I9 I IT, t._ i.tip Number of sheets Revision Date Title a" (c c c� Size of Septic Tank`w ca.l(cv►s Type-of S.A.S. - Description of Soil ©-Z 4° Lesen m p,i S^ubsai 1 • 24" - 1-4, c1 c.-k Y/Y cal owl Sar-Q Nature of Re airs o AlteratfOns(Answer when appheab s) :`-- A.f a ,--Date last inspected: Agreement: f/ The un ersi ned a es toe s/i the construction and maintenance o'f the afore described on-site sewage disposal system , g , in accordanc ith the provisions of Title 5 of the Environmental Code and riot to placerahe system in operation until a Certifi- Cate of Compliance has been issued by tl )Bo, d'4M Signed Dated!T D Application Approved by Date Application Disapproved foae following reason4,� Permit No. /0, Date Issued���` 21 A- -————— ' —————— `-- _. r THE COMMONWEALTH OF MASSACHUSETTS- BARNSTABLE, MASSACHUSETTS ` ~ w C,,ertiftrate of Com-p1tance J THIS IS TO CERTI , that the On-site Sewage Disposal System Constructed )Repaired(fj)/Upgraded( ) Abandoned( )by _ at off' ` een constu& ,ii accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer 4M Designer The issuance of this+permit shall not be construed as a guarantee that the system will function as designed. Date Inspector a --�- — ------- ------------------- No. s' ,— - 5 THE•COMMONWEALTH OF MASSACHUSETTS l Alt/PUBLIC HEA 'i DIVIS'IOW743ARNSTABLE MASSACHUSETTS F Mi0pool *potem Conotruction Vern--Wc_C /&i�)o 17 Permission is hereby granted to Construct( )Repair( )Upgrade )Aba don( ) System located at i T and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her r duty to comply with Title 5.and thhe'following local provisions of ecial conditions. Provided.`Construction-must be comp eted wittui�"three years of the date of this pe�init- Date: Approved by 7/14/2020 ShowAsbuilt(1700x2800) TOWN OFBARNSTABLE LOCATION FrM fPn1-lel4b Ult SEWAGE# •VILLAGE OCI PfJ,e ASSESSOR'S MAP&LOT CS 7,-Too/-Io INSTALLER'S NAME&PHONE NO. N4� 1' SEPTIC TANK CAPACrIY 7tt.t60tJ LEACHING FACILITY:(type) Sf'L)&IIILS (siu)J.3,4 Q i✓A- 17 NO.OF BEDROOMS BUILDEROR� G;Il�fal� PERmrrDATE: 1%-9 B COMPLIANCE DATE: 7- 30 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottum of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feprfif leaching faci'ry) y 2�/`9�y Feet F /a&]Furnished by '���' � / A, As:57' Aq-ya, N0001 `3- 3q:16, 3 s https:HitsgIdb.town.barnstable.ma.us:8431/Home/ShowAsbuiIt?mp=071001007&sq=1 1/1 1 C , TOWN OF BARNSTABLE LOCATION EWE k iCl a SEWAGE # VILLAGE D1I,eri,de, ASSESSOR'S MAP & LOT 6.2 J INSTALLER'S NAME&PHONE NO. t� SEPTIC TANK CAPACITY Aft) LEACHING FACILITY: (type) 2� �� ' (size) 3 •t'�10� I� NO.OF BEDROOMS 'Sr� BUILDER OR§W�DNE PERMIT DATE: — 9 f COMPLIANCE DATE: :Z- y�C�"J Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fe �, leaching facility) y� / Feet Furnished by '� ,�' f� � `y �1 s7 "J A5 Aq -�a; 11o, 001 Ca ; J6" 16, ASSESSORS MAP NO' 10 7 N PMCELNO•,<1aL---g'1�7 Fee---- ------- BOARD OF HEALTH TOWN OF BARNSTABLE ApplicationArVell Con5truction Permit Application is hereby made for a permit to Construct (r"), Alter ( ), or Repair ( )an individual Well at: ------— -------—---7Location Address Assessors Map and Parcel I'Soot, Owner Address DAS�a-%J I A—-------------------------- ------------------------ ----------------- Installer — Driller Address Type of Building Dwelling------------------------------------------------------ Other - Type of Building —------------------ No. of Persons--------------------------------------- Type of Well 'y Purpose of Well--- Agreement: The undersigned agrees to install the aforidescribed individual well in accordance with the,provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Ce *fica of Compliance has been issued by the Board of Health. Signed date -z_ Application Approved B date Application Disapproved for the following reasons: date Permit No. Issued ------ date BOARD OF HEALTH TOWN OF BARNSTABLE itertificate (Of (Compliance THIS IS TO CERTIFY, at the Individual Well Constructed Altered or Repaired (ml by--- Installer at A 17, 101-V-e kc; has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No./,fi .V"/- ated-e-:!'.Zzi;41:52b f�-0 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector V r T I,/f� d4ro1 �-- No.--K ----- -- Fee---- - ------ 1 BOARD OF HEALTH ,.. ..II T WN OF. BA'RNSTAE�L-E r e 5ucatio[icatio ermit ApplicatioJ,n� is here by°male f / ruct (✓), Alter ( ),.or Repair ( )an individual"Well at: - - - .� r� Location ° Address. — — ess A' ,'" ri $Assors Ma and Parcel LP / 4 Owner Address - - - --= - - Installer - Driller ° Address, Y' Type-of Building. --- ' ------- Dwelling,-----. --' - .. 44 Other- Type of Building --- =- --- No.. of Persons_--------- ------------- - Type.of Well-'-y w C ---- - Capacity---- - - —- -- --- - Purpose of Well----UZ �� Agreement: t ,' ff The undersigned agrees to.install the aforedescribed individual`well in accordance with thetprovisions-of The i "Town of Barnstable Board of Health Private Well.Protection Regulation - The undersigned further agrees not to; place the well in operation'until a ;Cer�'ficaa .of Compliance has been issued by.the Board of Health. L�f��•-�(J —-- ----'------ —Signed t date Application Approved B Application Disapproved for:the following reasons: -, ----=--- - — .- ------ --- j. —-- j� =-- - -- _ _ " date— • . � — 1. —. -� ,I ys �^ •- Issued --1 -^ R -__ Permit No. - L - -- - --- date ?e!N T !i4¢VR Ni}Y P�+a•14 'sr.�S:e3KS$s•?iMs�i!?�Splb4o0i°itNes`�e:4&RiQif69il�ii.�iw69.:4b4i96gG�nlrsX�li9sli9ii`eRLQsMltli9i9GKAiQilHiCifilat•i!G1i�aT.Y�f�!�f'iTti4i.� BOARD OF. HEALTH TOWhI OF BARNSTABLE l t ertifirate Of Compliance THIS IS TO.CERTIFY, at the Individual Well Constructed ( ' ),'Altered ( ) or Repaired (6,1 1 Installer F,N F *has been installed in accordance with the provisions:of the Town of Barnstable Board of Health Private Well Protection Regulation as.described in,the application for Well Construction Permit Ndel_g !��ated. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY, `. DATE- ---- -- - -- Inspector.---------- -=— ---___ �2+i2bR2eiRo.Cc+$S.iSI.ARitw@i0L43WS4r'sY.mmi.MitlGOo1L C�.'YYlii9i9Q#:[WGOiWi`r1iAL4d96Di469ATi9tiTsPi4 SSiADYTi bN�S4ai`?ti.K4WTf:Ai&G'V 1•^9a!3�m!.ti���i4ira6441ir04i9vs.W.i�4!i2'iai+!i9.i.i�6T9i�sii�: BOARD OF HEALTH ;,. ,.� TOWN OF. BARNSTABLE Seri Congtructionpermit r: No. /` �" / Fee- `'� Permission is hereby granted 0 �U to Construct(� Alter( , ), or Repair (f ) an.Individual Well at:' No - �r^ [E /t7° f� U f fu llo--- -- — -- . - - -------` Street. as shown on:the application for a,Well Construction-Permit No. ell - - -=== Dated--- --- �.r--— ----- --- DATE Board of Health s � j _�� i S S 3 � 4 ti ti �' ti i t x r r? J J � � i �--` , •{ to JSS k � G J "� t �..,�� �� "5 �'� W J t Cn �? f f , a .4._.� S ' � 1 TOWN OF-BARNSTABLE y60/ a.LOCATION tie le-I k AA - - SEWAGE # � 7'ly . t� „.AGE_USR x-s--•yam, �.,..,,•,r;�,,_,...;m.._.._ t:�.::,�:g::;_ -_ ,. ` � VILLr ASSESSOR'S MAP & LOT-j�—t�U/�de INSTALLER'S NAME&PHONE NO. YPi ' SEPTIC TANK CAPACITY I LEACHING FACILITY: (type) 2� �rlr s (size) S 3 r07 i✓ �� NO.OF BEDROOMS WELDER OR:-�� PERMIT DATE: 24 � COMPLIANCE DATE: CU Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feqpf leaching facility_)Q fZ Feet Furnished by V w L d a - i e _ 9 ' i W i M I , -t 11 LI• -� ..�.. -y� I ao .<v A j Han J dy'. �\ /r 0 t0 J �. C Z$.O I r !: ope Pt ■on q NoisyJs , boce �QC 'Flt Y a^ `� r t vc�I 129 ,,. . / Fii/1 �,�� p, 4� 23. Q 23.6 200D Gc.11o+�l 23,E boxFIRISHED GRADE `t 22.3_ a ' � 22.Q L��c�vivr, 3MA.X MUM FlLI. PEASTONE -� I t •�- evvervvvvvev vvvvevevvve TeaStatic t343c 1 vvvvvvevvv vvvvvvvvv --�A vevvseve• vvvvvsvrr 3/4" TO 1 1/2 ., -� _ ;-tr 4. 3 0 �tCas" ' - tj? - - - - vvevv�e vevvvvv v 10 DOUBLE .. C" •� v v v v e v e v v e v `> ntaryd paa� boy* Beachh 11u,, vvvvvve vvvevv♦ vvevvev ♦vvvvv �'3 1 ♦vvvsv vvvvev WASHED STONE - ter � Ught 52 �- LOCATION MAP rn r I COTVIT QUADRANGLE SCALE: 1:25,000 r S ACT/o/v A -�Q ASSESSORS N Q, t*► �No £L. 13,7 l MAP 71 PARCEL 1-7 ,5C4 A t0 J 1 1 I r� ZONES: r y AQUIFER PROTECTION OVERLAY DISTRICT I L O T 1 g 9 Y { ZONING DISTRICT: RP - 1 MINIMUMS N/F JAMES F. CLEARY 1 ARE, m 43,560 S. F. I �t: FRONTAGE 20 I WIDTH 125' FRONT SETBACK 30' 1 i SIDE* SETBACK 15' REAR SETBACK I s' POLE 9 24.0 24. 1 r FLOOD ZONES C �• ' FIRM COMMUNITY PANEL No. 250001 0018 D CB/DH FND� REVISED: JULY 2 1992 �' EL � nc i 0 24.33 L Ccri Tic,+ The �ro f-c lzr �Ivu .� JI\owv�,� � l-I e rc a n w 24.3 _ q I Gj -5),: owrl 0I eQurn+1LLI e uA jJ b No ack I�cY�Fcc� W fh �1 1 N 86 02 07" E r l o c t 330.70` 25 x 24.8 x 24.4 �I a pcci a I F I vcxJl �•I a zurc4 20��. 26 .. x 2.5.8 x 25.4 W 14 - tN of �.� ,y w----- f ------ I q-- - - RICHARD r x 27.1 - / A. RAXMR g 16, O JC Z e Vp B40 4 ; ` . . j r 624.2 I _ N1 I N -4 - . PROP House: � b > 00 y � N ELPK 23 69' / l ct 1 1 h 7n L N POLE ' 1 '• J I � N x 24.2 4. O 24.9 M - i x 26, x 25.3 0 i I 23.8 ..._ .. ,v r - - _ I � � I o C) 46,557 S. F. f �i I Poiclt \. .� I PAO�P, 6A�th� I '� 1.07 Acres C WA/k I Vl . fn x 25.4 N 88*51,09" W x 24.2 HYDRANT 169 25 328.22' 227. x 24.3 24 24.0 7- x 24.5 E B/D 24.43' SITE PLAN s o „a w N AT Q0 o rn n N DESIGN DA?'lA #163 PINELEIGH PATH ` � 4 [3c&r'ooms w/ GC4rba3l Gri✓+CQcr �I OYSTER HARBORS w OSTERVlLLE N MASS. Des1�u F�o� : Ilo 9- bdrn14 = 4y© Sp,:Q 2� 4 FOR i 5 U5 2,000 G«Il�t, Ta"k (Twa Co,.�par�Ftncnt) , L O T 1 9 7 J�Pl7G TR/JK q� X Z00/c"s g8� ollcmS .'. L�ACFIING cJYgT>�ivYl �0 J 0, 74 5t=l q = 595 F * 5cn% = 892 -b PK FND 4 � �P � cQ S N/F AM P. MANZI [EL � 24.38 DR. GARRETT GILLESPlE v,I) WiAll 41 srorlG 12 'w,a x s5-u �on s,A 2j(,?'( I Z' + s ' > : 2(o0 JF Er Z4,z - o SCALE: 1" 20" JANUARY 9, 1998 f�ST DH1 A 1 P - 733 Rev. San'jar'�' 20) 1998 i3 o H'rn••• 12' x 5 3 = 6 3 65F /14 /8q BAXTER & NYE, INC. 24" I) ��clry PI'I� 4r this �.-ot is Ccnkru,ll� vsfcr\��IL� �lilG,sfr� illlill_ Flrc 1�+ .t I = 812 MAIN STREET I-. 1,�.1;I so.. I OSTERVILLE, MASS., 02655 Cla4,� T 2)L oc-c.h o unc Q r3rovr\c- u+'I I t-ic s c.vr- 7._'.. ~ (.508')-428-9131 � JGrruhr,+r\i N07�S Onl .J�rTiG /i'li✓K , � � .! � I�c�ur� IDr,c�r ^h-c) .AH4 ercC.ca�Ja'I"lovi s^ iti-1��. ' �r�Jcc f-• �Ii� +' �c•i'c'•r ,� r I7Jc iu.r, ` �t �JC 1 H7c Ics y �Itan c rn„+ I01efl "hull +v\nkc- -tka rt rrukrr-4 vino-+ f i (;auk t-o TWO COMPARTMENT SEPTIC TANK REQUIRES TWO WEEKS LEAD TIME 'San' r�cQ C-'o-rnvh LJa tr. 7�cpt . (4 2 8 �(p9 1� . a I TO ORDER FROM SUPPLIER. �1 3) TT,� con�,a� i �« �,r� 1 pF w f' GRAPHIC SCALE rll -i o S C C�J v"<. �a r'a r i c.�'-C c i',i i I'�`_. 'Y'0 i i THE FIRST COMPARTMENT OF THE SEPTIC TANK SHALL BE SIZED FOR -I o..�t\ �Jc� Ct'cY -"(- t ccrostruclic'n av\ 1�1i� r�la�1 A MINIMUM HYDRAULIC DETENTION TIME OF 48 HOURS BASED ON THE �- '1) Tnsta II ri;,crs as rc,�,it-r,0 -t-, w,}t;,,I �" o -fih1��, Q� 20 o i I 4I eo DESIGN FLOW; THE SECOND COMPARTMENT SHALL BE SIZED FOR A 4, I MINIMUM HYDRAULIC DETENTION TIME OF 24 HOURS BASED ON THE DESIGN FLOW IN ACCORDANCE WITH 310 CMR 15.224: MULTIPLE �' T YSUBSTITUTEDSTEPII�N ` �, /� I1 �trvc+urns buriccQ -jnur (4) ••{-cct �7f ,�,cre. a ✓ �c��Jrcf -fn COMPARTMENT TANKS. TWO TANKS IN SERIES MAY BE ALLYN ( IN FEET i i1/o CfJzhr a WIL$U+'1 + +r-C' �=C be I-E- Z� �oacQ,�� SUCH THAT THE FIRST TANK IS 2000 GALLONS AND THE SECOND TANK uC�\+cv lar IS 1000 GALLONS AS PER 310 CMR 15.225. I3,7 - - I LG No 30216 '"�.� � � i inch 20 t� .ivies 98000 (SITE01.DWG) I