HomeMy WebLinkAbout0035 QUAIL ROAD - Health 3 5 Quail Roads Y� ` �,�
1 Osterville
A= 117=014
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THE COMMONWEALTH OF MASSACHUSETTS
2 BOARD OF HEALTH
ate OWN OF BARNSTABLE
AVVIkation for Dhayi ial Worko Tonitrur#ion Vrrntit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at: F16_
\L
-- Location•A re•ss .......... -•--or Lot No.
Owner Address
11 ' -------------..@..-----------`R4s`
Installer Address
UType of Building Size Lot............................Sq. feet
r Dwelling—No. of Bedrooms_____________ _____________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons______________________ --_._ Showers ( ) — Cafeteria ( )
p-' Other fixtures _______________________________ _ _
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons Length________________ Width---------------- Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length..................... Total leaching area....................sq. ft.
Seepage Pit No-_------------------ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •--- ------------- - -- --^--------------•--------------------
O Description of Soil__ .`. - ----...-•-----�` -------..t=S•--------•--•----- ��`�
x
U -••-----•--------••___-•-----___•---••----•----•---••--•--•--•-•-•-•-•----•---•--•-------------------•--•--•-•-•-------•--•---•-•--••----•--•--_-•--••••--•-•---•--•••-----.._.......--------...--------
x ••------------- ----------------------------------------------------------------------------••-•••------_-_---------------------...--------•-------•______•---_.____--•___-__•••----••-
U Nature of Repairs or Alterations—4nswer when applicable.__1���`��1--------1,--____ �__'___------
QJt_ �� > 2iz2.-.--•-- ._. b nv L+ ....5'o22vu�
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compjiance has been issued by the board of health.
Signed . a�-- ......................... -------- � .... `4- . ......
Approved By ..............`. ..Z., ............. -� .. e.---- .
Application Disapproved for the following reasons: . ............................................................ . ..........................
--------------------------------------------------------------------------------------------- ----------------------
q'► Dace
Permit No. F 1...... --------------------- Issued --------------- ......... . . -- .......................
Dace
No. ' 3 y FEB
/THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
AvOration for orkri Tonitrnrtion rrrmit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at: A
------•----------------------------•---------•--------.....------•---------------•-•--••-•....----
Ic.ation•A ress or Lot No.
W Owner ( Address
a
Installer Address
U Type of Building Size Lot............................
Sq. feet
►� Dwelling— No. of Bedrooms------------- ----------------------------Expansion Attic ( ) Garbage Grinder ( )
a'4 Other—Type of Building ..--.----- No. of persons----------- Showers
g -----------•------ P ( ) — Cafeteria ( )
d Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid capacity------------gallons Length---_---------- Width---------------- Diameter....------------ Depth................
W Disposal Trench—No. ..................... Width............--...--. Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter.....---.........--. Depth below inlet---.--.............. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by--------------------...................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water..--...----.............
44 Test Pit No. 2................minutes per inch Depth of Test Pit--.---.............. Depth to ground water------------------------
1:4 .............................-......................................................................--------- ... --.........-----..----
D Description of Soil..Q.:..,:5.............~�J S x .•-•--•---------•-•------.....--��+�----•----... ........-----------------------•-•-------•-•---
v ----••-•••-••---•••---------•---------•------------••----------------------------------------------•---------------•----------•-----
W
----------------------------------------------------------------------------------------------------------------------- --------------•--•-------------------•-•------•-•-------•-••--••--.. -----
U Nature of Repairs or Alterations—Answer when applicable_l�S``�L�---------1_�,���.......C?�LLO ..__S
- ------- --
....t......................� -�• ''�'?R Q�--------- )--- ----- ------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Com�pliaann�ce has been issued bqy the board of health.
Signed .. --...n1 -:L'' ..-------?.. G' ..:.
.4
Date C
ApplicationApproved By ---------- —�^ ..K�- ^ -- -----------------------------------------.---------------------------------- ...� � (
Application Disapproved for the following`?reasons: .............. ....................................... .......... ........... .............. ......-- ..........
...........................—............------------.....................--------------------------.........-----------------------........................-----------------------.......----- ........----'Dare
PermitNo. -------- .L-/...-...3.6..y------------------- Issued ........----- . -- ....---. . .........----- ------
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C�Ertif rate of Compliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaire�.(��
by .....l ie. ` i-----------�'ti+s ((
AbInstaller
at ......�- ----- -----------V) --------- °� .........-- .......1............ - - ......... -..........
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. -.._........_�.- - ..L/ dated
l'- ..... ----------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
........../ ----e---f . .. . !. ------ �------- Inspector - -------------------............... -------_---------------------
DATE
------------- ------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS ' v y
BOARD OF HEALTH
C, TOWN OF BARNSTABLE
No...../ 3l C/ FEE
..................
Disjumal Workii Tonotrurtion "an it
Permission is hereby granted....- ---•-•--Wit'•)-! --••--------------------------------•-------••--•--•----
to Construct ( ) or Repair L(�an Individual Sewage Dispoosal System
at No........ �4=----.....•.�-=
Street 7 QQ
as shown on the application for Disposal Works Construction Permit No ���_,.��?: ... Dated.._....- .4. -'................
------------- " -.............................................
. � G........................ Board of Health
DATE...................... .--.......�....--....-- f
FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS
AsBuilt Page 1 of 2
TQWN OF BARNSTABLE '
LOCAf10N QU�1} Rc' SEWAGE#_-SY- 2/Y
VILLAGE OSR(V% ASSESSOR'S MAP&PARCEL.117 ' O I y
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY SW
LEACHING FACILITY:(type)
NO,OF BEDROOMS
OWNER /� ,GGO/Mirk
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet
Private Water Supply Well and Leaching Facility(if any wells exist
on site or within 200 feet of leaching facility) feet
Edge of Wetland and Leaching Facility(if any wetlands exist
within 300 feet of leaching facility). feet
FURNISHED BY?_W e4J 1 Q0 o h 10&
A Q
3 l as�' asb
90 413
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http://issgl2/intranet/propdata/prebuilt.aspx?mappar=l 17014&seq=1 3/30/2017
TQ WN OF-BARNSTABLE L06ATION GUM SEWAGE# C1 q— 2� /v
VILLAGE 0STQ,(Vi1k. ASSESSOR'S MAP&PARCEL L/
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1.SW
LEACHING FACILITY:(type) 10 Tl Pi rQ U/1 (size)
NO. OF BEDROOMS
.OWNER. G corm IC k
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet
Private Water Supply Well and Leaching Facility(if any wells exist
on site or within.200 feet of leaching facility) feet
Edge of Wetland and Leaching Facility(if any wetlands exist
within 300 feet of leaching facility). feet
-10&
FURNISHED BY'T �Tp�
W .
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Ca �1
v
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ic
TOWN OF BARNSTABLE
LOCATION__ 3 S 0-14a I g"04d SEWAGE #
VILLAGE aS` d ASSESSOR'S MAP & LOT/I7 d �/
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)1p.-l-'V Aa size)
NO. OF BEDROOMS_�P* - R PUBLIC WATER
j BvOR OWNER ,
DATE PERMIT ISSUED::
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
D
o'
Y
i TOWN OF BARNSTABLE
LOCATION - i,> `, �• SEWAGE#env`
VILLAGE (`- .:6e _A SESSOR'S MAP&PARCEL
e
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY � Jr�
LEACHING FACILITY. (type (size) 3c3t(,p �!
NO.OF BEDROOMS j
OWNER Dj6, /.�
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
'Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY ��
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Commonwealth of Massachusetts ! P /
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Vgluntary Assessments
°f 35 Quail Road
Property Address
Jim McCormick 3
Owner Owner's Name/
information is Ilere4uired for every Ostervi MA '
02655 4/25/15
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector: t
key to move your
cursor-do not James Ford
use the return key. Name of Inspector
Company Name I
P.O. Box 49
Company Address
Osterville MA 02655
City/Town �tate Zip Code
508-862-9400 S12482
Telephone Number License Number •�J P• !;(�.Nf f
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and completeias of the time of the inspection. The inspection
was performed based on my training and experience in.the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system'inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
:I
❑ Needs Further Ev uation by the Local Approving Authority
Af
5/6/15
Inspeatem
s Signature Date
The inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DER The original should be sent to the system owner
and copies.sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13 Title S,j .cial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 V
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments
35 Quail Road
Property Address
Jim McCormick
Owner Owners Name
information is
required for every Osterville MA 02655 4/25/15
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
0
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.
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):
a
t5ins•3/13 Title 5;0fficial Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
• I�
• 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
`l 35 Quail Road
Property Address
Jim McCormick
Owner Owner's Narne
information is required for every Osterville MA 02655 4/25/15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
- ❑ Observation of sewage backup or break out or hi�h static water level inthe distribution box due
to broken or obstructed pipe(s)or due to`a broker., settled or uneven distribution box. System will
pass inspection if(with approval of Board of Heart):
❑ 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)`
❑ The system required pumping more than 4 times;p year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ 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:
i.
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a b60ering vegetated wetland or a salt marsh
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
i
44- Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Quail Road
Property Address
Jim McCormick
Owner Owner's Name
information is OSterville
required for every MA 02655 4/25/15
page. City/town . State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of HealtN.(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 abs t,orpion system (SAS)and the SAS is within
I
100 feet of a surface water supply or tributary to surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems;
; I
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility o�system component due to overloaded or
clogged SAS or cesspool i'
® Discharge or ponding of effluentq.to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distributi in box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins-3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts i
a
Title 5 Official Inspectioh Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
d� 35 Quail Road
Property Address
Jim McCormick `I
Owner Owner's Name
required for
is every
Osterville
required for eve MA 02655 4/25/15
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.) i
Yes No
El ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of mes pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or priv;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 fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure�criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form,]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system owner should contact thb Board of Health to determine what will be
necessary to correct the failure)
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of ti tributary to a surface drinking water supply
Elthe system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area-IWPA)or a mapped Zortg II of a public water supply well
If you have answered"yes"to any question in SectionE 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, or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The sysem owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
. 35 Quail Road
Property Address
Jim McCormick
Owner Owner's Name
information is
required for every Osterville MA i 02655 4/25/15
page. Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ 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?
® ElWere as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspe ted for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the;baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For exampl@, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
w
Number of bedrooms(design): 4
4 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for exampl f: 110 gpd x#of bedrooms): 440
t51ns-3/13
Title 5 pfricial Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
'I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 35 Quail Road
Property Address
Jim McCormick
Owner Owner's Name
information is
required for every Osterville MA 02655 4/25/15
page. Cttyrrown State Zip.Code Date of Inspection
D. System Information
a
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) . ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use?
❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
unavailable
Sump pump?
❑ Yes ® No
Last date of occupancy: unknown
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.)-"
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13
Title 5bfficial Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
. �i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Quail Road
Property Address
Jim McCormick
Owner Owner's Name
information is Osterville
required for every MA 02655 4/25/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
i
,
General Information
Pumping Records:
Source of information: unavailable
Was system pumped as part of the inspection? i ❑ Yes ® No
If yes,volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
,l
❑ 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):
t5ins•3/13
Title 5.01ficial Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Ins'pectio'n Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
°t 35 Quail Road
Property Address
Jim McCormick
Owner Owners Name
information is
required for every Osterville MA 02655 4/25/15
page. Cltylrown State Zip Code Date of Inspection
D. System Information (cont)
Approximate age of all components, date installed(if known)and source of information:
system installed-7/1/1994
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan): > '
Depth below grade:
feet
Material of construction:
❑cast iron
®40 PVC . ❑other(explain):
Distance from private water supply well or suction line:
feet • i
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade:
30"
feet
Material of construction: i
®concrete ❑ metal ❑fiberglass El polyethylene ❑
pol eth
Y Y other(explain) i
` I
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal.
Sludge depth: 2
t5ins•3/13
Title 5.Official Inspection form:Subsurface Sewage Disposal System•Page 9 of 17
j:
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Quail Road
Property Address
Jim McCormick
Owner
Owner's Name
information is
required for every Osterville MA 02655 4/25/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 30
Scum thickness + 2
Distance from top of scum to top of outlet tee or baffle 6
Distance from bottom of scum to bottom of outlet tee or baffle 10
How were dimensions determined? measure
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 tees were present.There was no sign of leaks a The covers are 16" below grade
,i
Grease Trap(locate on site plan):
.:1
Depth below grade: n/a
feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene El 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:
h Date
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
�i
Commonwealth of Massachusetts
Title 5 Official .Inspection Form
Subsurface Sewage Disposal System Form-Not for Yoluntary Assessments
'( 35 Quail Road
Property Address
Jim McCormick
Owner Owner's Name
information is Osterville
required for every MA 02655 4/25/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I
pi
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene
El other(explain):
N/a
Dimensions:
Capacity:
.gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level; Alarm in working order: ❑ Yes ❑ No
Date of last pumping: 1
Date
Comments(condition of alarm and float switches, etc):
"Attach copy of current pumping contract(required). !s copy attached? ❑ Yes ❑ No
t5ins•3/13
Title 5 fh'ficiat Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
• Commonwealth of Massachusetts q
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r< 35 Quail Road
Property Address
Jim McCormick
Owner Owner's Name
information is OSterville
required for every MA 02655 4/25/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert even
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The D-Box was normal
I "
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.):
*If pumps or alarms are not in working order, system'is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
' 1
t5ins•3113 Title 5 Official insp
ection Form:Subsurface Sewage Disposal System•Page 12 0f 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
p( 35 Quail Road
Property Address
Jim McCormick
Owner Owner's Name
information is
required for every Osterville MA 02655 4/25/15
page. City/Town State i Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number: 10-infiltrators
❑ 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.):
There was no sign of failure.A camera was used
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
I
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
t5ins•3/13
Tito 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
i
V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Quail Road
Property Address
Jim McCormick
Owner Owner's Name
Information is
required for every Osterville MA 02655 4/25/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/a
,! II
l5ins•3/13 Title 5 Official insp
ection Form:Subsurface Sewage Disposal System•Page 14 of 17
i
,.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°< 35 Quail Road
Property Address
Jim McCormick
Owner Owner's Name
information is
required for every Osterville MA 02655 4/25/15
page. Cltylrown State Zip Code Date of Inspection
D. System Information (cont:)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal,system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
poor
� OIL
a 1/o `13
3 % q9
t5ins-3/13
Tltle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
' :1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
`( 35 Quail Road
Property Address
Jim McCormick
Owner Owner's Name
information is
required for every Osterville MA ' 02655 4/25/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
1
❑ Shallow wells
Estimated depth to high ground water: 15'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
Topo and water contwrs map
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
see above
Before filing this Inspection Report,please see Re iiIort Completeness Checklist on next page.
l5ins•3N3 Tille 5 Official Inspection Forth;Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
INK fTitle 5 Official Inspectioh Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
35 Quail Road
Property Address
Jim McCormick
Owner Owner's Name
information is required for every Osterville MA 02655 4/25/15
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information-Estimated depth to high gri undwater
® Sketch of Sewage Disposal System either drawn!on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION - 1151 t522-1
Property Address: 35 Ouad Road
Osterville, AM 02655 .
Owner's Name: Jim McCormick
Owner's Address: _
Date of Inspection: October 7..2008 '3
Name of Inspector:(Please Print) James M.Ford - a
CompanyName: JamesM.Ford .
Mailing Address: P.O.Box 49
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 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
Ne Further Evaluation by the Local Approving Authority
Fai
.Inspector's Signature: Date: October 15:2068
The system inspector shall sub it a copy of-this i spection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and.the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to.the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
""This report only describes conditions at the time of inspection and under the conditions of use at that
time.. This inspection does not address how the system will perform in the future.under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
d,
Page 2 of 11 R
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 31 Ouail Road
Osterville.MA
Owner's Name: Jim McCormick
Date of Inspection: October 7. 2008
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 15304 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
�f.
1
i t
Page 3 of I 1
s f
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 35 Ouail Road
Osterville,MA
Owner's Name: Jim McCormick .
Date of Inspection: October 7, 2008
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 it 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
1
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 I 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:
t
3
1
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 35 Ouail Road
Osterville,MA
Owner's Name: Jim McCormick .
Date of Inspection: October 7. 2008
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 ''/]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 1.00'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 detennine 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 109000 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: 35 Ouail Road
Osterville, MA
Owner's Name: Jim McCormick.
Date of Inspection: October 7.2008
Check if the following have been.done: You must indicate"yes"or"no"as to each of the following.•
Yes No ,
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows.in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ — Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of.sewage back up?
✓ _ Was the site inspected for signs of break out? .
_✓ Were all system components,excluding the SAS,.located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions;depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the,site has been determined based on:
Yes No
' ✓ _ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)):
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 35 Ouail Road
Osterville.MA
Owner's Name: Jim McCormick
Date of Inspection: October 7. 2008
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
Number of current residents: 2
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): n/a .[if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd .
Basis of design flow(seats/persons/sqft,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/user
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: unavailable
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped. _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool'
Privy
Shared system(yes or no) (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:
7114194-as built card
Were sewage odors detected when arriving at.the site(yes or no): No
6
r
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 35 Ouai1 Road
Osterville.MA
Owner's Name: Jim McCormick
Date of Inspection: October 7,2008 .
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: ✓ (locate on site plan)
Depth below grade: 30"
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: 1500 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet'tee or baffle: 30"
Scum thickness: 2"
Distance from top of scum-to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were Present. The liquid level was even with the outlet invert There did not appear to be any signs ofleakaQe
The covers were 16"below grade.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete ._metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 35 Quail Road
Osterville.MA
Owner's Name: Jim McCormick
Date of Inspection: October 7, 2008
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: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D-box was clean. No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 35 Quail Road
Osterville,MA
Owner's Name: Jim McCormick
Date of Inspection: October 7,Z008
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: 10-Infiltrators
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 Infiltrators were dry and were clean. There did not appear to be any signs of failure A camera was used for the inspection
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth=top of liquid to inlet invert:
Depth of solids layer:,
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no): ,
Comments (note condition of soil,signs of Hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: .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
R
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 35 Quail Road
Osterville,MA
Owner's Name: Jim.McCormick
Date of.Inspection: October 7,2008
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.
A Q
A
90 �3
3 y( Y9
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: 35 Ouail Road
Osterville MA .
Owner's Name:, Jim McCormick
Date of Inspection: October 7 2008
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20+/- . 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: Toga ayhic and water contours niays
Checked with local excavators,installers=(attach documentation)
Accessed USGS database-explain: '
You must describe how you established the high ground water elevation
UsingBarnstable to o ra hic and water contours maps, the nu s were showingi roximatel 15'+1-to roundwater at this
site.
This report has been prepared only for the septic system and components described herein. This septic system has been
as of the date of inspection. This report is not a warranty or guarantee that the system will
inspected and passed
function properly.in the future: There have been no warranties or guarantees,either expressed,written or implied,`
relating to the septic system,the inspection,this report andlor any components of the septic system which,have not
been located and inspected.
11
3
i
No. � Fee
1
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
fpplitation for Bisposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair(L_<pgrade( ) Abandon( ) ❑Complete System n ,vidual Components
Location Address or Lot No. 31 va, �QS�efL,'f Owns N ttte,Address,and Tel.No.
Assessor's MapMarcel
Installer's Name,Address,and Tel.No. -rO ���g/ Designer/'Name,Address,and Tel.No. /
5�! %�9�z .�nsi _'C0n6u1&!S1TJ"C
o$�YB-33 Y
Type of Building: c�
Dwelling No.of Bedrooms ( AA Lot Size 3Sl Z� sq.ft. Garbage Grinder( )
Other Type of Building �S,�G�Bt� C�p l No.of Persons Showers( ) Cafeteria( )
Other Fixtures F
Design Flow(min.required) //Y� r gpd Design flow provided S7 . 3 gpd
Plan Date /�' `� Zo2( Number of sheets ( Revision Date
Title J�"E•2 6" A".,:;.0sew
Size of Septic Tank 1EK,,4 1 ISW0 ' / - y,Type of S.A.S. 3-TM G , A f
Description of Soil c4 r'-q —
Nature of Repairs or Alterations(Answer when applicable) " 6 Pe04e®s',°d tf—w 2) �p7(
Q1 sAs �3- s-oo C, 16 A C-e/f s 7 S4r n, �
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 nnt tn piner,ae.systern in operation until a Certificate of
Compliance has been issued by this Board
Signed Date
Application Approved by ct3, Date
Application Disapproved by Date
for the following.reasons
Permit No. '2U / Date Issued I Z�
I.4�11
-No• i, { Fee
J THE COMMONWEALTH OF,MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
4plication for,Disposal Opstem Construction Permit C>�
Application for a Permit to Construct( ) Repair•(1- Upgrade( ) Abandon( ,) ❑Complete System [S Individual Components x
Location Address or Lot No. �{t14, j ac4&•r�,f�Q Owner's N e,Address,and Tel.No.
00
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. j-0 If' j�. Designer's Name,Address,and Tel.No.
F
Type of Budding:
we ling oBe'D drooms Lot Size 3`�, ��` sq.ft. Garbage Grinder O
Other Type of Building T,' h �,'o f No.of Persons Showers( ),Cafeteria( ) <�
Other Fixtures
Design Flow(min.required) / Q4 r- gpd Design flow provided �( gpd
Plan Date Number of sheets a Revision Date
Title �j
J, r, e6, r'"�lc".,O: 1
Size of Septic Tank EX-%st7 e IJ'� G,(16 �9-fnr-,Type of S.A. /ill
Description of Soil 542,�, 2
Nature of Repairs or Alterations"(Answer when applicable) Fc,;14 S'Af D eon(
cxrtn� 5"AS
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 uotto:place th.,,_-e system in operation until a Certificate of
Compliance has been issued by this Board o4lileallill,
'
Signed _ ^ 71„ Date '" / Z
Application Approved by Date
Application Disapp oved by ® ,. : Date
for-the following reasons
•Permit No. J ' Date Issued d 'g
------------- ------ - - - _
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned(
at &I• 6�1% o_ ,( C'-or `I Ap has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.7 0121- 3 dated i-
Installer j `g. . Designer 5UA h h r t - •�t�
#bedrooms l 5x•;s F;h Approved design flow y�r gpd
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
No. 7- n 4'. 3'3 ! Fee /E!(,/.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Bisposal *pstem Construction Permit
Permission is hereby granted to Construct(, ) Repair( ) Upgrade( ) Abandon( )
System located at i g zipir P_
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
j�Title 5and4l e following local provisions or special conditions.
Provided:Construction must be completed within_ three years of the date of this permit.
1 _�~ L �A
. Date �r� � Approved by
..:..
Town of Barnstable
Regulatory Services
Richard V. Scali,Interim Director
BMWSTABM
Public Health Division
039. A1�
rru•+ Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-8624644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 1118/2021 Sewage Permit# 2021-339 Assessor's MaplParcel 117/014
Sullivan Engineering&Consulting, Inc. Joyce Landscaping,Inc.
Designer: Installer:
Address: Address:
711 Main Street!PO Box 659 68 Flint Street
,
Osterville, MA 02655 Marstons Mills, MA 02648
9
9/21/2021 Joyce Landscaping,Inc.
On was issued a permit to install a
(date) (instal
Ro-�ler)
septic system at 35 Quail L=e,Osterville based on a design drawn by
i (address)
Sullivan Engineering&Consulting, Inc. dated 9!9/2021
(designer)
X I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
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. Strip out(if required) was inspected and the soils
were found satisfactory.
I certify that the system re renced above was constructed ' ce with the terms
f t e IAA approval letter (if applicable) ��P�JH oF.MAssq
Boa : CHARLES T. cc
Q ROWIAND
CIVIL
( stall 's Signature) p No. 52s99 �^)f
F9FctsTER��
NAL
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:1SepticlDesigner Certification Fonn Rev 8-14-13.doc
ASSESSORS REF.: a�
Map 117 Parcel 014
OVERLAY DISTRICT:
\ N GP - Groundwater Protection District
p AP - Resource Protection Overlay District
NO AP Saltwater Estuary Protection District
to � • � -
jj
FLOOD ZONE: �Y
!nil �0 Zones X (0.211. Annual Chance)
- & X (Min Flood Hazard)
'n Community Panel No.
j #250001 C0544 J
645 0 July 16, 2014 LOCATION MAP.
�,123.83' R- Scale: 1 2000'f
waane
(40' priva{e i M
C Z
(F d) ' deaf pavement ZONES:
r Edge r RC RF-1
Existing SAS , ' l Area (min.) 87,120 SF (RPOD) Area (min.) 87,120 SF (RPOD)
to! be Removed i Frontage (min) 20' Frontage (min) 20'
and Filled with Width (min) 100' Width (min) -125'
Clean Sand 5.00 ` 1
Setbacks: Setbacks:
r �- Front 20' Fron t 30'
-- \ 79.01, R= 0.0! Side 10' Side 15'
TH Rear 10' Rear 15'
\ 10' Min.
Guy2.` 201
Eiec' war one e�ag I 100' Buf= -
,BoX E ,� king v I'riH- O
i. PN�.: N P N
�p k, j .. - DIRECTIONS:
Sto
CB/QH / ne f
(Fnd) ,/ / Drive / ? beM From Hyannis - Follow Main Street to the West
! ��F �k� End Rotary, Take third exit onto Scudder Ave.
Pr etaA e 1 Roof z ag\ode°fie Turn right onto Smith Street at the stop sign.
g everhang ,� 0 0° nth` Continue on to Craigville Beach Road and left REFERENCES:
3 e Se i 1 onto South Main Street. Continue over the
oX \� cc) 1j �� bridge to Osterville, and left onto Bay Street Deed: C212704
Garage / w and right onto Blue Heron right onto Quail Plan: LCP 26 722-S
\ \ j o Existing Septi Slab EL f /. m E 1 ' Lane #35 is on the right.
\ / o Per Tie Card Slab
E - /
Lot 24\ / o to Remain -
35, 30f SF / •-' - r _-r N°�)
\co
�=w d n2
. e
Z° °nc Variance Request
�MFEjnu°\ G q
/p.2q° Counter Variance
\ �� L oo` /; / X Proposed SAS >3' Deep
- No Increase in Flow
• __ All H-20 with vent and <6' Deep
V/ OJFo /
W 5e G 22 5 Raise
CL
\ �n
w R 50 eck
1
Brick
M N # 35 Patio / / �.'
`�'� ( � ,,- PERC'TEST. 21-235
2 Sty w/f Lawn
/ / PERFORMED BY.CHARLES ROWLAND,PE SULLIVAN ENGINEERING
N / °• Dwelling �. ' ! / / / / , Iw 1
J Lawn / Stump // ! f /j / 9�
&CONSULTING,INC.
j / / SOIL EVALUATOR NO,13586
I / / j WITNESSED BY:DONNALD DESMARAIS,R.S.-TOWN OF BARNSTABLE
N F /j/j f / ��p0, `L AUGUST 26,2021
/ Dec'/ P° �� // i / j j�,/ 5\ o< SITE PASSED
John J. Rosalyn L, Doran Trs. pe o\ A i / o �`
J.J. Doran Trust •`._ ` \nd°or J- /// / /j /� e'���a�o\ _ -
/ / o TEST HOLE 1 EL.22.0 TEST HOLE 2 EL.20.r
I W 2 Ap LA.YER lOYR 3/2 Ap LAYER IOYR 312..........
VERYiiARIf GRAYfW BRDijVN VERYI?ARIC GRAYISHBRDWN
6' / #•
ZG� / J'•,j �,e �o\\ j l ` / �ri� �/ ,l j/ / 6 :......... Stir►DYEOAM.....•.:_:....._ 21.5 6 '. SANDY E OAM...... . 20.2
PERC TEST Bw LAYER lOYR S/8
i4.1 25 GALLONS GONE IN 4 MIN. YELI;t1TISHBRDWN
j r j �' o PERC RATE<2 MIN/11V(LTAR=0.74) 36 :.LOAItY S:4ND.....:. 17.7
.....
/ / / f/f co 2 ' Bw LAYER IOYR 5/8 •20. C LAYER IOYR 613
Law( I100' / �� j Lawn / j. / / r..> YELLOWISHBROWN PALEBROWN
// ./f ` ° / //// ! 1 0 34' LOAMY SAND 19.2 132' MEDIUM SAND 9.7
CLAM 10YR&3 NO GROUNDWATER ENCOUNTERED
I W 3 PALE BROWN
13211 MEDIUM SAND 11.0
NO GROUNDWATER ENtbUNTBRED
/ / o
\ / N/F
� -0 1 Phyllis W Cole,�\ �
^`O le
_ 0 -.c.r 15' BldgOffse
,- _ ..
R.
' k h 5' 17 50",�
CB/DH
150.40' y(Fnd)
IW 5
CB/DH j
\ IF oyt L�G (Fnd)
-A
SEPTIC NOTES
1.Location of Utilities Shown on This Plan Are Approx.At Least 72 Hours
Prior to Any Excavation For This Project the Contractor Shall Make
the Required Notification to Dig Safe(1-888-344-7233)and contact
Sullivan Engineering&Consulting Inc.(508-428-3344).
2.The Contractor is Required to Secure Appropriate Permits From Town
Agencies For Construction Defined by This Plan.
3.Whenever Sewer Lines Must Cross Water Supply Lines Both Lines Shall
Be Constructed of Class 150 Pressure Pipe and Shall be Water Tested to
Assure Watertightness. In General,Water Lines Shall be Constructed in
Coonaination With COMM Water,and shall be in Accordance DESIGN DA TA
With 248 CAR 1.00-7.00&310 CMR 15.00. Single Family
33.5' 4.A Minimum of 9"of Cover is Required for All Components. -4 Bedroom @ 110 GPD
5.All Structures Buried Three Feet or More or Subject No Garbage Grinder
to Vehicular Traffic to be H-20 Loading.It is the Engineer's Total Daily Flow=440 GPD
Finish Grade Recommendation that H-20 Always be Used. Use a 1500 Gal Septic Tank
6.Install Watertight Risers and Covers to Within 6"ofFinished Grade
3' Max. Over Septic Tank Inlet and Oude4 D-Box,and One Leaching Chamber. LEACHING AREA
9" Min All covers are to be maximum 18"for concrete or 24"'Cast hun
Compacted Fill Filter 440 GPD/0.74(LIAR)=594.6 SF Required
7.Septic System to be Installed in Accordance With 310 CAM 15.00&
Fabric Sidewall=2(12.83'+33.592'=185.3 SF
And/Or 248 CAR 1.00-7.00 Latest Revision and the Town ofBarnstable Bo �=(1Z.83'x 33.5)=429.8 SF'
Ven t Board ofHealth Regulations.
2" 1/8" - 1/2" Total Provided=185.5+429.8=615.3 SF(455.3 GPD)
8.All Piping to be Sch.40PVC.
3-500 Gall Pea Stone
Chambers -03' H-20 9.D-Box Shall Have a Minimum Inside Dimension of 12;and a Minimum
12.8' 3/4" - 1 1/2" Sump of6". LEACHIlVG CHAMBER DESIGN
LEACHING Double washed
CHAMBER Stone 10.The Separation Distance Between the Septic Tank Inlets and All Pipes to be Schedule 40. Use
g
hi L l 500 Ga.Leach
ing Chambers in a
Outlets Shall be No Less than the Liquid Depth.Inlet Tees Shall Extend
a Minimum of 10"Below the Flow Line.Outlet Tees Shall Extend 14" 12.83'x 33.5'Double Washed
4' - 10" Below the Flow Line,and Shall be Equipped With a Gas Baffle. Stone Field as Shown.
" Crushed Stone i- 12' - 10"
CROSS SECTION OF CHAMBER
- NOT TO SCALE
11% Pitch Min.
Pro H-20 Existing SAS
D-Box to be Removed
All Unsuitable Material to
SAS DETAIL PLAN VIEW be Removed and filled
with Clean Medium Sand
Per- 310 CMR 15.255(3) Charcoal Filtered Vent
p�
1 yOT TO SCALE Final Location to be Determined
at time of installation or in
accordance with Landscape Plan
See- Note 6 (typ.)
F.G. EL. 21.5f F G. EL. 21.3f F.G. EL. 21-22
EL. 19.1
Flow Equilizers
As Required
EL. 17.9 Existing
1500 Gallon Top EL. 17.80
Septic Tank EL. 17.65 17.20 H-20
to Remain To be Confirmed D-Box EL. 17.04
LEGEND: Prior to Instalation 16.80 Leaching
CDT Cedar Tree To Be Installed On Chamber
Stable Compacted Base _ Bot. EL 14.80
HT Holly Tree �JNOF��s� Bedding, ..T"s
DT Deciduous Tree g T qc Inspection Port, /.f..Errcouriaerea Rr?move 8c Replace '
R & Boffels AII..Unsurtable. .So.ils ..lAfithin .5..of
AW
CT Coniferous Tree •' as Per Title 5 The..Outer Perimeter of The �. stem_ -
" �, y n
Utility Pole
-E- Electric
�t.�� EL. 9. 7
-G- Gas No Groundwater
Per Test Hole 2
* Lifightght Post d Flag DEVELOPED PROFILE OF S YSTEM
EL. 5.5
0 CB/DH Per Flogged Wetland &
OHW- Overhead Wires
NOT TO SCALE Seasonal High Groundwater
25 Elevation Contour
TITLE PREPARED BY. PREPARED FOR: NOTES:
Site Plan
1) The structures shown were located on the ground by (J)Proposed Improvements Engineering & conventional survey methods on 311912021 =
rri
Atohn Stoddard �c Galen Lar a R le 2) The property line information shown hereon was r
Consulting, Inc.I y y y compiled from available record information.
35 Quail Road �Sos,4zs.3344•P.O. Box 659.711 Main Street Osterville MA 02655 3) The datum used is NAVD 1988, a fixed mean sea
Mass. � � level datum obtained by RTK GPS performed by SullivanBarnstable (OSter ille) seci@suilivanengin.com•www.suilivanengin.com Engineering & Consulting Inc.
rl
Draft: CTR ASL Field: WHK CTR 20 0 10 20 40 80 4) Topographic information was collected using both
conventional survey method and RTK GPS on 3/19/2021.
DATE: SCALE. Review: CTR Comp:/Review CTR/JOD
September 9, 2021 1 = 20
Project: Ryley Project#• 410009