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HomeMy WebLinkAbout0010 REBECCA LANE - Health °10 Rebecca La-ne * Osterville u + J u i 0 fl No. /5/ Fee _ THE COMMONWEALTH OF MAS$ACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS appuration for oiopooal 6potem Conotruction Permit Application for a Permit to Construct( . )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. i-A h 15 Owner's Name,Address and Tel.No. 10 Rebecca �. ,Osterville Donald Tatro Assessor's Ma arcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service Dan Johnson Type of Building: Dwelling No.of Bedrooms 3 exist Lot Size sq.ft. Garbage Grinder( ) Other Type of BuildingResidential No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow gallons. Plan Date 3 n 02 Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil° m ark i i i m sand Nature of Repairs or Alterations(Answer when applicable) replace fail G a cz with 2 d ryw e l l s ( 25L X12W X2 H) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by o d of He Signed a a Date �`��� ✓� Application Approved b Date � G' Application Disapproved for the following reasons Permit No. ELM 2 G x6 4--1 Date Issued Fee m n 1 Win, THE COMMONWEALTH OF MAS§ACHUSETTS Entered in computer: Yes -PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS App(tcation for Migpogar *pgtem Con!5truction Permit 1 1 � Application for a Permitito Construct( . )Repair(X )Upgrade( )Abandon( ') ❑Complete System ❑Individual Components, Location Address or Lot No. i,,A N 15 Owner's Name,Address and Tel.No. 10 Rebecca 'lam. ,Osterville .Donald Tatro Assessor's Ma arcel Installer's Name,Address,and Tel.No. e. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service Dan Johnson P O Box 1689., Centerville 804 MaOster-ill - Type of Building: Dwelling No.of Bedrooms 3 exist Lot Size sq.ft. Garbage Grinder( ) Other .Type of Building Residential No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow gallons. . Plan Date _3_u_n 1) Number of sheets Revision Date Title .. 1 Size of Septic Tank Type of S.A.S. 4 Description of Soil: med i urn sanA Nature of Repairs or Alterations(Answer when applicable) renlace f a i 1 -,ac wi t-h. 9. rlrwo] I ( 25L X12W X2 H) Date last inspected: �{ Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by d of He It + y f Signed i r Date t73 Application Approved by Dates'/!/s6 Application Disapproved for the following reasons r r Permit No. Date Issued .�` r,/ •—e° e i THE COMMONWEALTH OF MASSACHUSETTS Tatro BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( ) Repaired ( X )Upgraded( ) Abandoned( )by Wm E Robinson Septic Service at10 Rebbecca Rd. , Osterville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Ne,, 11400- dated Y fl*'. ,00 0 Installer Wm. E. Robinson Sr. Designer Dan johnc;on The issuance of this permit shall not be construed as a guarantee that the system ill function as design d. Date iC�J Inspector r No. sf IGs Fee $5 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Tatro lwifspogat *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) System located at 10 Rebbecca Rd. , Osteryille and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this p5mut. Date: ;,il: "`l -^ ,/r Approved b I_ � * r TOWN OF BARNSTABLE LOCATION Lgn)16 SEWAGE# Aooa— `�ILLAGE ASSESSOR'S MAP&PARCEL 14 tg —U5 1 INSTALLERS NAME&PHONE NO. '-'45 SEPTIC TANK CAPACITY ocz QGA l©n LEACHING FACILITY:(type)2—SaOA,3\ (size) o`�S 1 a X� NO.OF BEDROOMS 7 CV-CtrN\W-rs OWNER PERMIT DATE: COMPLIANCE DATE: J� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility `5 t•-t— Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) r'r Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching lity) Pc Feet FURNISHED BY IN Q REY-1 �: Pam O 9 O � 0 In Rt � a On .0 TOWN OF BARNSTABLEL LOCATION SEWAGE #., -200a VILLAGE ASSESSOR'S MAP & LOT IY6 "0-52 INSTALLER'S NAME& PHONE NO. P,ab�:�,soffit Scvn�i e 7'�5 972�a SEPTIC TANK CAPACITY " ?O O �5 size a$ LEACHING FACILITY: (type) r / ( ) Y./�2 ' f NO. OF BEDROOMS 3 ' BUILDER OR OWNER ` N PERMIT DATE: ` _COMPLIANCE DATE: 3 Oat IT Separation Dist"ce.:Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water,Supply Well and Leaching Facility (If'any wells exist t` r. " on site or within 200 feet of leaching facility)i '• Feet Edge of Wetland and,Leaching Facility (If any wetlands exist 'rt within 300 feet of leaching facility) Feet Furnished by �'� ® \, R� � { � � �: w k � � A �, �, s n �' � � k � � - �;, . � � � �s` C� N,;I �q+' Y (1 _ Yp ` ,. ' l� 1 Y _ SM/0t NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. y PERCOLATION TEST AND SOIL EVALUATION EXEMPTION ' FORM hereby certify that the engineered plan signed by me dated 3/ g j o2 , concerning the property located at ` t - /o i� cv� rL�.�a o srvi meets all of the - following criteria: • This failed system.is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor method when applicablej Please complete the following: A) Top of Ground Surface)elevation (using GIS information) 6:Z B) G.W. Elevation �3 +adjustment for high G.W. DIFFERENCE BETWEEN-A and B / )t- 7-err P cT PL LFatiw,t*! c SIGNED : DATE: 3/8 � NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder.percexmp r I* TOWN OF BARNSTABLE LOCATION /O Re�,b�cr-OL SEWAGE #. .200,2 - 101/ VULLAG ASSESSOR'S MAP & LOT S� INSTALLER'S NAME&PHONE NO. Pak,�soffit Scan 1i'C 7 15 99262 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 5 o C a/ - PrVIa>ell�5 (size) -7777 NO. OF BEDROOMS 3 _ BUILDER OR OWNER ` � PERMTTDATE: COMPLIANCE DATE: 9 0d2. i 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 ail a c i r i f r i Commonwealth of Massachusetts W Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 10 Rebecca Lane Property Address Donald & Louellen Tatro Owner Owner's Name information is required for Osterville MA 02655 9/25/08 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. Important:When filling out A. General Information forms on the computer, use 1. Inspector: only the tab key to move your Carmen E Shay cursor-do not Name of Inspector use the return ry key. Shay Environmental Services, Inc. Company Name c'7 2 ---1 _ ,1 185 Ashumet Road Company Address CYN co Mashpee MA c 02649 City/Town State Zip Coded �,.. 508-539-7966 3080 > Telephone Number License Number CD r— � m B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 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 ❑ Needs Further Evaluation by the Local Approving Authority �P�jMOFMgss CARMEN s� o E. 9/25/08 o SHAY Inspector's Sign ure Date 0 �9T1 The system inspector shall submit a copy of this inspection report to the ` W/sr ty (Board of Health or DEP) within 30 days of completing this inspection. If the system Ied ystem or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. � SDI 10 Rebecca Lane,Osterville-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 • Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 10 Rebecca Lane Property Address Donald & Louellen Tatro Owner Owner's Name information is required for Osterville MA 02655 9/25/08 every page. City/Town 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: ® 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: No evidence of liquid in SAS 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 10 Rebecca Lane,Osterville-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Rebecca Lane Property Address Donald & Louellen Tatro Owner Owner's Name information is required for Osterville MA 02655 9/25/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cost.): ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. , ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 10 Rebecca Lane,Osterville-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 10 Rebecca Lane Property Address Donald & Louellen Tatro Owner Owner's Name information is required for Osterville MA 02655 9/25/08 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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: 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 ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 10 Rebecca Lane,Osterville-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ° I K. 10 Rebecca Lane Property Address Donald & Louellen Tatro Owner Owner's Name information is required for Osterville MA 02655 9/25/08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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- 10,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. k 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. 10 Rebecca Lane,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 10 Rebecca Lane Property Address Donald & Louellen Tatro Owner Owner's Name information is Osterville MA 02655 9/25/08 required for every page. Cityrrown 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? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® El 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)] i 10 Rebecca Lane,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 10 Rebecca Lane Property Address . Donald & Louellen Tatro Owner Owner's Name information is required for Osterville MA 02655 9/25/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate 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: Last date of occupancy/use: Date Other(describe): 10 Rebecca Lane,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 10 Rebecca Lane Property Address Donald & Louellen Tatro Owner Owner's Name information is required for Osterville MA 02655 9/25/08 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system El '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: March 18, 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No 10 Rebecca Lane,Osterville-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Rebecca Lane Property Address Donald & Louellen Tatro Owner Owner's Name information is required for Osteryille_ MA 02655 9/25/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 4 Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks, plumbing properly vented Septic Tank(locate on site plan): Depth below grade: 4feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 10' x 5' x 5' Sludge depth: 40" below inlet Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness 1/4" Distance from top of scum to top of outlet tee or baffle 8° Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured 10 Rebecca Lane,Osterville-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Rebecca Lane Property Address Donald & Louellen Tatro Owner Owner's Name information is required for Osterville MA 02655 9/25/08 every 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.): Inlet Baffle and outlet tee present and in good condition. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 10 Rebecca Lane,Osterville-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 10 Rebecca Lane Property Address Donald & Louellen Tatro Owner Owner's Name information is required for Osterville MA 02655 9/25/08 ` every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons .Design Flow: gallons per day, Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Equal with all two outlet inverts. 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.): No evidence of leak or cracks, riser present. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 10 Rebecca Lane,Osterville-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Rebecca Lane Property Address Donald & Louellen Tatro Owner Owner's Name information is required for osterville MA 02655 9/25/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: two ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS fuctioning properly, no evidence of any liquid around SAS. Located cover and opened. No liquid in SAS - No Riser Present 10 Rebecca Lane,Osterville•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Rebecca Lane Property Address Donald & Louellen Tatro Owner Owner's Name information is required for Osterville MA 02655 9/25/08 ' every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Privy (locate on site plan): l Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 10 Rebecca Lane,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 ' Commonwealth of Massachusetts Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 Rebecca Lane Property Address Donald & Louellen Tatro Owner Owner's Name information is Osterville MA 02655 9/25/08 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. �tip 4aq a� s US 10 Rebecca Lane,Osterville-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 m Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 10 Rebecca Lane Property Address Donald & Louellen Tatro Owner Owner's Name information is required for Osterville MA 02655 9/25/08 every page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 13 feet(5' separation to bottom of test hole maintained. 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: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Obtained design plan and reviewed test pit data by Daniel B. Johnson, IRS, CSE dated 2/27/02 10 Rebecca Lane,Osterville-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 LOCATION 5EW&C.4E PERMIT UO. -- - - - LBT2_ VILLAGE IW57aLLER 5 ► WE ADDRESS �ST�LL - - - - - - - - BUILDER 5 ' Q &MF- ADDRESS DATE PERMIT ISSUED DATE COMPLI & ACE ISSUED : — — — i b 3 cl - - I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE LT /..( ..........OF......).,1�.�t�......... .... ... ............................ Appliratiuii -fur Uhipoml Works Tatuitrurtion Vrruiit ; Application is herebymade for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Syst .at• j�- - .. .-- ----- : 2 ------------ .� ---- ...-----. c Lwfition- d s or Lot,,No. .... -- . • .... .. .� ` .... ................... ..........••••• -�.... ...........---- owner t Address was ..... .... ......... . ......... ............................................ .................... Installer Address QType of Building Size Lot----------------------------Sq. feet U DwellingNo. of Bedrooms--- -- -----Ex Expansion Attic Garbage Grinder — P ( ) g ( ) aOther—Type of Building ---------------------------- No, of persons.--------------.--.--------- Showers ( ) — Cafeteria ( ) Q' Other fixtures -- ----------- w Design Flow............pia---------- -------gallons per person per day. Total daily flow..............3_®...�_ --.-----------gallons. WSeptic T<<nk—Liquid capacit� gallons Length................ Width--.......------- Diameter--,-------------- Depth---------------- Disposal Disposal Trench—No --------------_---. Wi t .-..-------_------- Tot th--.................. Tota eachi area-..�.®-�sq. ft. Seepage Pit No.l�-Q - e �--=--.... Dept#�� t .. .......-..... of a ng area------------------sq. ft. z Other Distribution box ( /%� Dosing tank ( ) aPercolation Test Results Performed by------- ------•--------•--•--••-••••••-••-........---•--•-------•------.. Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of "Pest Pit..............--.... Depth to ground water.-----------------.----. ri, Test Pit No. 2--_-----------minutes per inch Depth of Test Pit----------_------. Depth to ground water------------------------ P4 -•-•--------- (------ (} ......... ... -------J O Description of Soil------------------- - ----Z----------� �E_ Z � � (.-�.--® �` - - --- x w UNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ -------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article YI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boar of hea gned :. 7 - Da e Application Approved By-----------.� . ............. •. - - Date Application Disapproved for the following reasons:.........................................................:...................................................... ...................................................... -------------------------------------------•-•----....--•---......----•----.....-------------------•---•--•---------.....------------. ...... Date PermitNo......................................................... Issued---_---------_------------.......................... Dati! No........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL ...... C/-(-� 'iti --------OF....... ."�-� ................... Appliration -for Ii.apoiittl Works Tonfitrnrtion Vrrniit Application is hereby made for a Permit to Construct ( �orepair ( ) an Individual Sewage Disposal Syst at•. `?� --•-••-•--- "-"-------------------'-••-�"/'--•---. .. ------ r� t ...................................................I�?Cam✓ Lo9dtion-t1d � Owner Address W tt •---•--••--•- .-'•-'-•-•'•••••-- / .Installer Address Type of Building Size Lot____________________________Sq. feet Dwelling—No. of Bedrooms. --•--•--•-----_____Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ___________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures F--••-------•---•-------------•-•-••---•-------------------- --------•-----•--------•---••--•-----------•--•-_•--•--- Desi n Flow............. gallons per person per day. Total daily flow____________________. W g � P P P Y Y ��--�J-- - gallons. Septic Tank—Liquid capacitA wgallons Length---------------- Width................ Diameter---------....... Depth_-----------. xDisposal Trench—No- ____________ «Ji ------------------- Tota gth-------------------- Tota achi area--_.3_�J- .sq. ft. Seepage Pit No._/.� D/ - €e _..._ De w tfil '--- ----•----•--. to ch}ug area---_------------sq. ft. z Other Distribution box ( )`% Dosing tank •�!l Percolation Test Results Performed by.... --------------------------------------------------------------------- Date------------------------------------ Test Pit No. 1----------------minutes per inch Depth of 'lest Pit.................... Depth to ground water-.--____--_-___-__-____. (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__-_---___---______----- ----- ---------------------------------------------•-••---------------------------- ----------- Description G O of Soil--------------------�- --` .. "• = `---------------------=�=-----•--------- �2 ----.,��t�-'= -=-.....�--�-------------- x W U Nature of Repairs or Alterations—Answer when applicable.--____________________________________________________________________________________________. ___•----•--------------• _--•---••---------------•-•--------------------------------------------------------•---------------•-----•-•-••------------•-------•-•----------------------------•-------•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by thhee boar of heal /S•gned�� ti_`_..... !_-•---------•--•• -- - � (� Date ' � Application Approved By r Date Application Disapproved for the following reasons:---------------------------------- V ------------•-•-•-•------------•••--------•-------•---------•- '-.....----'•---••-•------------•---•-----•---------------------'----•-------•-••-._•.-.•.----•--•--'--......__.._.------•--•----._.._.-••--....-------------•••-•---------------•-------•---••-----•-'-- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT / -° ......oF.....:/ '- .......... .......... .......................................... Qrrtifirate of f.11,11nipliattre THIS IS -0 CERTIFY, That the?I dividual Sewage Disposal System constructed ( or Repaired ( ) K / } nstaller at........ .� .... r has been installed in accordance with the provisions of Article_2I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----PP P �==`----•,�'._.i�---7...... dated---------�.-_./"e'--_Z�--....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTJON SATISFACTORY. � DATE......... �� Ati ---- •---•-• Inspector.-- .- ' -- ram °, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH U � ......... .... ...OF.._�r,./�fr '..-..-..--........... No...... ............................... FEE--- ................ . �i��o�ttl ` ork� �on�fr �tt�al rrmit Permission is he eb ranted_________ /_- �-------�__'___ _ to Construct i o`r e air ( ) n I�idividual Sewage Di. osal Sy e at -= 1 (/ Street ' as shown on the application for Disposal Works Construction Permit No.------ G._____ Dt _. _� N__.r-- ..� ------------------------•='• e� e DATE........ •�/--..._._... ..................•'-'------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 177 irk( �_Rf� i fit- 1 / ' -�.'�J (.•mil./, - � � 4_ .L•2y ] �y.-V } Nays to s a o,�� �• '' ,C�.�V GC's""` s� p �y� ....`y .17{ � ��' �4 3+�`��y �i•5' Y � s .. r rr xs3 , 04 � x _ ...AMM ' `- - • r`�J</�.F�G.�.�" ��:l J`�3`�. '���[./�� �-77'"7�. ��i�®I ®�+���l ri`/�r�i�`..�y F�� �Kz� >dRs�p/�q��/®I�/s �y • C7 �i3 � <� is � �r ` �ean I�7�i•�o .wise 4���' "�e • r e � p T/•/�T' 72/O aCJId•D/a,/G ' eLdOtAA.cd CAW 7r/-//& ®G eMM /S HOC,9r& � PA/ 7W .V W0 ENN PV0,00aA.1 AM" �T.i/ad�7" ./7` E , c7E5 ®A/�'O�Ai1 TAD �R� '✓1a57'A �40.QF � ; x ,�n_ 3tsol-eL ,QPIS OI7 r we 7"i�WA. Ofr z9�!°:d9P�4! L°9 T47d�C TES • � AR�N[�E 3 1 C Fp r/•� ��p �e A.��g e.e rev `�TA _ ff RStS�.•� id `fie`x-4� 5.1 v = m r Y k a .r aC�GaQ;, / ��� � fL � .�_ � DISTRIBUTION BOX PL A Al i. � TEST PIT DATA H 10 _r •5(AtC : 1 "z Ao ' Performed By: Daniel B. Johnson — MOVABLE COVER / 4"SCH 40 OUTLET LATERALS DISTRIBUTION 80X TO MEET R A MINIMUM OF THE FIRST SHALL BE SET LEVEL OTWO = ,r i REQUIREMENTS OF 310 CMR I DST i Date: February 27, 2002 15.232(WATERTIGHTNESS --` FEET AND CONNECTED TO EACH B+ LINE 1�w CONSTRUCTION,ETCI ,� Z.__� WITH SSOLIDISCHI 0 PVC PIPE TP-1 (aL. 97 .1) 4"SCH 40 NO OF OUTLET; o -I MECHANICALLY I TONF I< 3/4"DIA I 'ALISHED _ ".. " = 97+a��` 4" 36" Bw,,� 10YR5/8 Loamy sand (MIN) 36" -132" C1, 2 . 5YB/2 ME;dium sand ` TABIFIFVFI AAA No Observed ESHWT q°kNae .P•r � ' 1 No Observer] Ciroun(iwater , 50 �0 97t� (,r,/r.) --____ >� PL`RCOLATIOW TEST DATA 150)(ilNUUNI, gVIT ,, 1 Date: E'ebrur-) t y 27, 200 j "W) ,r"F40%ii%F.rTInN ,, 1 MI)iItI ,1' ,1)1"ti'r'Kit r q',t r`nN1 HF t t ,!� O IfaAt rjnA ak 1 r►fMf� 6 T AMU,Crf h - �1 t',1 11 1 = Soil Class: Clasm 1 (0. 74 G/SF ) 1I►dl',111 t, r,1lAllt I'.t rt 1 1 1 "t.yVIN J e rc Rate: < 2 MF'1 ( !a l ) Depth of Pero Teat 36" - 54" _....[ItA1 NIN �.. " Ii C)Et't'WEI.Lt: . 1/4 ' 1 i SCHtDVLE 1)' lEL1CVl1T10Ns tf t I ' 4 Il.r W' I I I WA',H F't A 4;T ONE 4 mama + 4 1 c,. . r r nee, c� _ f ' t ! pV[HAI.I.I..fAJ.�111NG AREA 114" 111.'"DOUBLE - - -� Iriv. Out. Foundation (pxis1. 1nq) �h . r 26LA12W,c? 14 - t WA.)HEDSTONE ' Inv . I n Sept It-, Tank (a.x i r,t i nq► '4 P; ', �� � tom, e..st 4=.s , < Irly . Out SlRpt l T-jtlk (ay icit ng1 T g �HrUP-K Ett.rtuG- No� :c Inv.(oo. 6t ��4 , ;' 1 tACHING DRY WELLS Ei-�= ;a ffEs ;ua. In I)� �fCi.k3t.9� .�tlrt 7~t[3X L �? f .,,or, �FE= 9}.SS �. Inv . Out: I)itit tibtrt ir?t) 14, ,47 `44 c)1. tUll)MEMEN S 1HE ocoK Inv. In trna rh I nu Dry WO I � 'a4 . III, �--- A'&"' —j REQUIREMENTS OF Nottom of i,�a+:'hinr2 Dry' W- 11 3tUCMR15_52 e {{ pit I."E�'k r 1I! , rttl °ett - NOTES l ' if I '.i� 1 . All construction methods shall conform to the Title V ( 310 Prr,i;l,yt�t1 r't.,rtt ,_,ur ____� -_... ._ ,1 (:MR 15) and the Barnstable Board of Health Regulations . /~ 00 `t'eat- tit i . There are no known Y ,;r � A?ti private o.. public weals within 100 Finished Floor Elevation E'FE 3eeeta/400 feet, respectively, from the proposed leachina Basement Floor Elevation OFE 3 , ExistingSAS be pumped and removed to p p prior to 4_/4N Water Line W_._... . irintalling the new Leachinq area . Gas Line �G 4 . No changes are to be made in the field without the approval f of the )(lard of Health and the design engineer. "�. Prop()sed l.pachinq area is not dwsigntn.(.J for use witti garbage disposal . ... - ..._ __..._..... ..__....___ ,..... .-. .._......,..__...._..-.,._____—.. .._.._.. _.. _..,_._ -- __._-._.. ^apr`o+tr (e [ /^p t[ . .,. [. hou 1; -. prior t o r+D of o !�Y r- y �F * a v ° c4oserW ' cj( E t rd('trlr t ,, n[?t t fy (�iq ria>`e �..� r tAR [ t'c'rn t<o" ,,o. Tea o` , * , ,st ruc-•t ion . (400) 344-7,`11 . �'Wrr �' ` cc f S� sue'-s,`v t^M[5 t o- iot F1'�"tCtprty ). .inP I n f trmatI,on t:akon frc1m SubdIviii,"n l)f I: trt+.:t, n 5 . [ ° A, 'pTt , - C I'lt. ln ?6� f3, I,c�t tr . ; gptic Pl:ati not, OUNTq! S rv,y A 9 '. s AN I 1" i �)I Z t,,'' ri t t �. A I N 40 M� to� a y.,r ' 1P r:,a , t , n i - c- 'a t` , -r7 kt -rtr *y t ti o . N G c, J F F f Ci. 'f c t r i ,,.•[_: a ce l t rFa ' T �1 z W I`vo, o ra , � ` t i ;+ r)11 11 ';' �1't�trJtt.� the G�rt?pct!lad loAching ;4L'i ;4 °r Ittl. I clti rl root°h "1 rttet'c ClotM°t n == te G G p0 t i 1 ait,I t 1 1, o w i t It 'Tit I 2 0 " t "^ '. • r.Ivl J Cn�t `�^ ti • • o 1 cs �' r I I i ( Horn I #jrlt.,p ,i l tt (.*mk r r' 1 1 r 1 r at i t r r i I I 1 %,arl+I t t+t , 11tlr,ll c JS .. ... r` ARC ? t r r l 17 ICDI I r 1'y 1♦ I r t �rr[II.t * rf a'ot vr4w/r4 J !R ° r S? 1 o„ `—* �e .,.,,>e �,�� r "r ri l 1 tal ltiltlri i .z :t f ,+2tltttaltal dill t, It�t , 'I'h . I „D ' ♦ �f M�� � { �sN`' ra'- r ,. ,�' . + ti \ r` ♦ ' ` 1 l u I t h-X l t l n. l �E� T�IC. � Y� r tr ryry 1 � C AI °+ car• O'rtib, [ ' w of lr .1 i ,)Ofn X I iced I tt yItls - 3.i(1 61,11 : � , it.. i{ttl Rdt.E[ Mill I .►�+ �. % .,,`" �r x ,.pry 7sa 1 (0 . 14 (i/ tIF) F v ti �� f r/ w ♦urNr+ t,r/ — Y------,— r� �� �,., fa ♦ w PROPOSED LEACHING AREA : �' 4� r IOG � t t o ( rr � t , t� r Vt, rr r 'r•r~ ♦ ° inl..nn [ ; �} : t"it 5' L X 1 L' W X .L H - -- ••,,• + y ,r tr1A4•'::. ;, ►, ,%... ... ti., l.0 it .. ...,� ; •.; . J , F 1 5 I ` ^+ _ t+R•.�u 148 VV J. 34 b �.A N^ .. ' '+. r •, +.e.e.' N ... s C 4(� J �C• Area: 1 4 8 SF X J. l 4 `'' G "/� t�� ••"� ¢° t ..1.♦«a 't tip 4,, Bottom Area : 300 SE' X 0. 74 G/SF 222_0 GPD � ! I Total Leachii g Capacity: 331 . 5 GPD � I J. ,1_"_= RCN .�.,_ �9 Ell sr(Nd `` ._ -- -9a —ti Ex sr��b f � y 10— ` 9q � I Ears r/k'v I 00 all i N _ c�rSr 'jT f of gar go 8vX ' i ALL0(Y M I I 94 i u)E(,LS cc W 1 1 J sl' s I t a t3 o N P Z O n R ; �si✓cv� TI-! DEL.= ,�6;+ I tad .� --- — No �b.S, Gw � j •'E��,�,'Cr SUBSURFACE SEWAGE DISPOSAL SYSTEM j l 7I � 10 Rebecca Road, Osterville� �:,�.. o , DANEL , a I �,t�i+►ttlrjl i+rl. SCALE: As shp APPROVED BY DRAWN BY J04w" V DATE: Daniel D Johnson D.1. Johnson No. 1077 Cr _ } Pr"red Donald Tatro (508) 428 - 0359 Aq - CrntOJ C +l � (,td0 flt?O OfQJ d+SQ Oti"60 �70 �tBJ Ot90 ItOo rprp 02655 1+t0 a+ Cirtt"r ^` I: ostezv e, F01 < 4 repay . ( 08) 420-1904 DRAWING NUMBER 4 � u Hop, / '".-/a' i /l /� j �`��'i By 904 Frain Street Suite III, oster.slle, UK 02655 J-784 N /v