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HomeMy WebLinkAbout0044 RENOIR DRIVE - Health 44 ,Renoir Drive yu Osterville P x` r y; �'� r s A = 146 122 ", a .4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 RENOIR DR Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD; MA, 02632 Owner Owner's Name information is O_STERVILLE MA 02655 9/8/07 required for State Zip Code Date of Inspection every page. City/Town Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the L computer,use 1. Inspector: only the tab key to move your Michael DeDecko -- cursor-do not Name of Inspector use the return key. Compass Realty Development Corparation --- Company Name r� P.O. Box 2384 - --- Company Address Mashpee Ma i 02649 City/Town State Zip Code 508 -221-5003 -- ' Telephone Number License Num ber B. Certification _ = I certifythat I have personally inspected the sewage disposal.system at this add re�s an d that th e 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 9/8/07 ---- ----- — Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection, If the system 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. ****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 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 34 EVSUN•08/06 Commonwealth of Massachusetts f Title 5 Official Inspection Form -- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 RENOIR DR Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 9/8/07 _ -- 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: 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 pipes)are replaced ry ❑ obstruction is removed 34 EVSUN•08I06 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 2 of 15 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments g 0 44 RENOIR DR -- - Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 9/8/07 every page. City(Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont,): ❑ 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 aseptic 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. 34 EVSUN•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 - - - --- _ Commonwealth of Massachusetts r Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments \a 44 RENOIR DR l Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 _ Owner Owner's Name information is required for OSTERVILLE MA 02655 9/8/07 every page. City/Town 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 El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® 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 1/2 day flow El ® 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. 34 EVSUN•08106 - 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 44 RENOIR DR Property Address C/O DAVID HOLT, TODAY REAL ESTATE11533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 9/8/07 --- every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ 0 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 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. 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. 34 EVSUN•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts -� Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments p 44 RENOIR DR Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 9/8/07 — every page. City/Town 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? El ® 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? ® El information 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. ® ❑ 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)) 34 EVSUN•08f06 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 �` 44 RENOIR DR ' --- Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 _. Owner Owner's Name information is OSTERVILLE MA 02655 9/8/07 required for State Zip Code Date of Inspection every page. City/Town 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 0 Number of current residents:. 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 Seasonaluse? ❑.Yes ® No N/A Water meter readings, if available (last 2 years usage(gpd)): Sump pump? ❑' Yes ® No N/A Last date of occupancy: Date Commercial/industrial Flow Conditions- k 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): 34 EVSUN•08106 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Official Inspection Form Title 5 p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 RENOIR DR ----- Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 _. Owner Owner's Name information is OSTERVILLE MA 02655 9/8/07 _ required for every page. City/Town State Zip Code Date of Inspection n D. System Information (cont.) General Information Pumping Records: N/A Source of information: 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 ❑ 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): I , Approximate age of all components, date installed (if known)and source of information: N/A -----Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 34 EVSUN•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts 0.1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 44 RENOIR DR _ Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name r information is OSTERVILLE MA 02655 W8/07 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 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 Comments(on condition of joints, venting, evidence of leakage, etc.): JOINTS TIGHT,YES VENTED,NO LEAKAGE. _- Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No ---------- --------------------------------- ------------------- r 1000 GAL. Dimensions: -- ---- 2„ Sludge depth: -- -- Distance from top of sludge to bottom of outlet tee or baffle 3211 1 Scum thickness -- 11" Distance from top of scum to top of outlet tee or baffle -- Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determined? MEASURED---- ----- 34 EVSUN•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Q. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 RENOIR DR Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 _- Owner Owner's Name information is required for OSTERVILLE MA 02655 9/8/07 -- 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.): NO NEED TO PUMP, TEE'S INTACT,STRUCTALLY SOUND, LIQUID LEVEL EQUAL WITH OUTLET INVERT, NO LEAKAGE, 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 ❑fberglass ❑ polyethylene ❑ other(explain): 34 EVSUN•08t06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form _ iT Subsurface Sewage Disposal System Form-,Not for Voluntary Assessments 44 RENOIR DR Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 9/8/07 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 OUTLET INVERT Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-BOX IS LEVEL AND DISTRIBUTION EQUAL, NO SOLID CARRYOVER, NO LEAKAGE. Pump Chamber(locate on site plan)" . Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 34 EVSUN•08/06 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 44 RENOIR DR -- Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is _OSTERVILLE MA 02655 9/8/07 required for State Zip Code Date of Inspection every page. City/Town 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: ❑ leaching galleries number: -- ® 1/60' 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.): SOIL-GRAVEL/SAND, NO SIGNS OF HYDRAULIC FAILURE, PONDING DRY,NO DAMP SOIL, VEGETATION -NORMAL. - Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 34 EVSUN•08106 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 RENOIR DR Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 9/8/07 _ every page. CitylTown 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): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i 34 EVSUN°08/06 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 44 RENOIR DR Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 9/8/07 -- 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. z -3 . 43 R3-46' �33 34 EVSUN-06I06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 RENOIR DR --------- Property Address C/O DAVID HOLT, TODAY REAL ESTATE,1533 FALMOUTH RD, MA, 02632 Owner Owner's Name information is OSTERVILLE MA 02655 9/8/07 required for every page. CitylTown State Zip Code Date of Inspection D. SystemInformation (cont.) Site Exam: ® Check Slope ® Surface water s ® Check cellar ❑ Shallow wells 30.0' Estimated depth to ground water: 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: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: BARNSTABLE GIS You must describe how you established the high ground water elevation: BARNSTABLE GIS -- ----- -- Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 34 EVSUN•08/06 L i Town of Barnstable FINE rqy ti0 Regulatory Services • &UMSrna�.e, Thomas F. Geiler,Director '� .•� Public Health Division Thomas McKean,Director - , 200 Main Street, Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts,Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report;this Division does not warranty the functionality of the septic'system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. F. 1 4_04' TOWN OF BARNSTABLE OCATION ������� ��- SEWAGE# ILLAGE 4J * ASSESSOR'S MAP&PARCEL -00��+5 '��� I. STALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO.OF BEDROOMS 3 OWNER PERMIT DATE: "��`"G 6 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility J Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet I, Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY i J� c i \ i y � t i p 1 ; _ . ' No. 1. i s _ Fee to o e: THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ,) Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpplication for -Migoal *p5tem Con6truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System O Individual Components Location Address or Lot No.l�L�j ,o? Owner's Name,Address and Tel.No. Assessor's Map/Parcel/��/ ��`� c-•rTy ���� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building �� No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 ' gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil: Nature of Repairs or Alterations(Answer when applicable) 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 b B Ar >0 t v I/ Signed Date Application Approved by Date Application Disapproved forte following reasons Permit No. ® fi' � 7 I Date Issued NO. ©� "' ,j "l��.I_. "r Fee /D t THE COMMONWEALTH OF M ASSACHUSETTS Entered in computer: �a- Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yication for Zip opal !60m Congtructfon Permit Application for a Permit to Construct( )Repair( ) Jpgrade( )Abandon( ) 0 Complete System 'El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. e, Type of Building: Dwelling No. of Bedrooms Lot'Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 2_7 gallons per day. Calculated daily flow gallons. Plan Datp Number of sheets Revision Date Title + Size of Septic Tank Type of S.A.S. t. Description,of Soil 1 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: a. 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 b B f It . Signed Date v J� Application Approved by Date f Al rr.Application Disapproved for the following reasons Permit No. aCD©to -- I Date Issued 1 ----------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance r.l THIS IS TO CERTIF 9,Q_0-V— atat the n-site Sewage Disposal System Constructed( )Repaired( Upgraded,( ) Abandoned( )b�°, � y .-Ov©-1 109 41P j erS has been construct d in a cordance with the provisio s of Title 5 and tlr for Disposal System Construction Permit No.�00 Co / 7 ` dated M c Installer UZ 12 < Desig o The issuance of this shal of be construed as a guarantee t at the sys e i n tion as desi cl �,,m Date Insp pee a No.�� �l� � --------------------------Fee _ - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mizpogat *pgte�ou5truction Permit Permission is hereby grantes��onstruct _)Rera�rr Upgra )Abandon( ) System located at y' G�J✓!j49 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: Construct i n m st be completed within three years of the d e of thi pe t. Date:_.._ ��� Approved by Town of Aarnstabte Regilatary Services . Thomas F.Geiler,Director Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Offs : 508-862-4644' r Fax: 508-790-6304 Installer&Designer Certification Forth Date: ° yo.4 ,n ,� A. � Designer: y v`k sU Installer: Address: :"'I LQI.,'RGI Q�i T� Address - -- -- r A► 6�5�7 on: �� was issued a permit to install.a dat (installer) septic system at _ V r 'agsed on a design drawn by Y (Address) 1 D AV 1 D M MS.0 — dated Ik TC (designer) " V 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 K distribution box and/©r septic tank. I certify that the;septic system referenced above was installed with major changes_(i.e. greater than 10.' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accora�ace with State&Local Regulati . Pl revision or certified as built by designer to follow: i '/'Install er's Signature) WWW L i `S r S,. i er's Signature) (A x Desi `r-Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT _BK ISSUED UNTIL, BOTR THIS FORM AND AS- BUILT 4CARD ARE RECEIVED BY THE BARNSTABI,E PUSLIC HEALTH DIVISION. THANK YOU. Q:Health/SepticMesigner Certification Form ,tt Notice: This Form Is To Be Used For the Repair Of Failed 4i Septic Systems Only t PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, 1 )AV, % Dui ,hereby certify that the engineered plan signed by me dated 'l �� �� , concerning the property located at meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering) and two percolation tests shall be conducted. • 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. • 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 be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation V0 +adjustment for high G.W. DIFFERENCE BETWEEN A and B l SIGNED : 1 DATE: o 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 AS eptic\p ercexemp.doc TOWN OF BARNSTABLE LOCATION �i�ce'�oddL �o� ��. SEWAGE# VILLAGE Q Jam' ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY • �iY��d'��s,.l�: ®® ® L�• LEACHING FACILITY: (type) ��' '�'��{� (size) •�` X�B X NO.OF BEDROOMS 3 i OWNER tp PERMIT DATE: COMPLIANCE DATE: � — zo 6" i , Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility � J 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 i �AL 2f ,Lb/ i w J A• TOWN OF BMRNSTABLE LOCATION SEWAGE # VAkLAGE 05 ASSESSOR'S MAP & LOT ITT-4L-)=1-R'S NAME& PHONE NO. ✓Lek-ond le SEPTIC TANK CAPACITY LEACHING FACILITY: (type) L-e✓1- ,;l e= / (size) /r'va � NO. OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: DATE: /s1,StQ��/an 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 e e J Z7 L _ N lei'i Gtc cvg � ro' y � Y NoJ..3:sS17.... THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH -..........oF..........(3.14- ... .../../ --( .L-. -.....__ Appliratinn for Uhgpviittl Workii Toutitrnrtinn Prrutit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: l 2 �. l� Y� ....••--•-••..••••--•--•• •/-.Q -. • •.......... ............................................ 05. ...................... ocation_Address _...... --------------------------- owner p� ` Ad ess•-•••••{- .......................................c.,..,�2 �,�_lej...JDI!1S:C-Q-` ....... � Installor Address ��� Type of Building Size Lot___ _ __________________Sq. feet U Dwelling—No. of Bedrooms________________ __._.Expansion Attic Garbage Grinder ( � U Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ................................. . w Design Flow..................5-57.............gallons per person per day. Total daily flow.................... .. --•--•..gallons. WSeptic Tank—Liquid capacityj(, b 0_Lkallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width.........:.......... Total Length.................... Total,leaching area....................sq. ft. Seepage Pit No-.�... ..._.:_ Diameter.................... Depth below i e ......... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing tank ( ` �y f -_..__.... r Percolation Test Resul s Performed by................... ............. . .:. ... .. Date Test Pit No. I_._.�rs inutes per inch Depth of Test Pit_..__. .. . epth to ground water. ___ . 44 Test Pit No. 2.....�___.minutes per inch Depth of Test Pit..... :............. Depth to ground water.... a •-•-•-=••----•-••-----•-•-•-•--- -• Description of Soil 1 j ® '~ f .. S.Q.%.. ... ........................... x ....._..... i= - -- -------------------------- 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 TITLE 5 of the State Sanitary Code— The undersigned further es not to plac*theys.tem in operation until a Certificate of Compliance has been is d by the bo health. Sig ------- -•-----••• .... ............................. •-- Application Approved BY•-•---• ...................................................-........ Application Disapprove o the following reasons-------------•-••-------=------•---•...._..-•---...----•-•--...-------------•--•----------=- ..__....•-••-- -------------- -------- -----------------------------•----__••------------•---------_-__-.. Date PermitNo.---•.............•---------..._-••-•••-••---••-••------. Issued•.•.........---•------•----....._•-••-•••-•.......--•-- Date uia�e - --- - -- - -_ - --- - - ---- �— ---- - c. ` No..ft.......�1.. 3� -- Fxs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r - 1 � . .............oF...... Appliration for Eliipoottl Works Tontrnr#ion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: tio ���ss•• ��,�c�/l c..� ffL�d ............ •--- ... ............. ---------------- ---------•-----_---------••- n ddr Lot No. v�Z.101 ..... <.Q... _... ......................--•-•• .......... ..... canr ddress —,f �/?�•-`--__-__--••--•-•-•------------------ _Installer Address U Type of Building Size Lot..Z.�� . ....... feet Dwelling—No. of Bedrooms................. ---------- ._ Expansion Attic ( Garbage Grinder ( _ Other—Type of Building ............................ No. of ersons__..._................_.___. Showers — a YP g P ( ) Cafeteria ( ) Otherfixtures ----------------------------•---....................------------------------------------------•-•.....----------- ------- Design Flow...................5-:-_-- --.-•--___gallons per person per day. Total daily flow............... .. .. _.._.____._gallons. WSeptic Tank—Liquid capacitv 2 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 ( ) .a Percolation Test Resujts Performed b ........................fE.. _.. Date.........��_._'._-��_�4_ _ Test Pit No. 1.... sminutes per inch Depth of Test Pit.... .. __/_ Depth to ground water. t1G,L,�� 44 Test Pit No. 2....._Z�.....minutes per inch Depth of Test Pit.. ................ Depth to ground water........................ Description of Soil................................................ - -�..._.. � '._---- -/.._ _ _a... x •----------------------•-••-------•••----...-----••---•-•-----•-•-••••••----••2 --1. ............. vf'G`l Q''� --•---•---••-•------•---.. U 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 TITALL 5 of the State Sanitary Code—The undersigned further agree t to place the system in operation until a Certificate of Compliance has been issued b he board of lie Sigx ----- -•••-•.......... ... ....2�_. to.. ApplicationApproved By,l.=-.--•-- ----•-•--•-------•....................................•-•..........._---••--•--• --_.��.- ate .._..----- Application Disapprove o the following reasons:---•----•-------•-••-------------•-----....------••---...----------•---------------------- ••-._._........•- ---•................•---............_----•-•••--••--•----•-•••••••--•------••••-••-.............................••••----••-•---•••••------•••-•••-•••----•••••-•......-- •---•....._••---•••••-•••-•--- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA OF. . ................ ...................................... Trrtif iratr of Tomphana THIS IS TO CERTIFY, That the Indivial Sewage Disposal System constructed or Repaired ( ) bY---------------------------------------Do'l .:e z............. --------.......-------------•-------•-•-•-•-------•-•----•- �+ -- •-----•-Insta 1 at.................................................... _ -t''� ` -P . 4. has been installed in accordance with the provisions of T '�T`LE 5 of!The State Sanitary cribed in the application for Disposal Works Construction Permit No.__li.-• .....__. 7_._7_._____..__. dated_.X........3 ....... .................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNC,TL9N SATISFACTORY. t DATE......... f:.. ? ................. .•-�yl ,J�. Inspector A.�......................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��jj� G � ' y / - ..............OF................ -.�.l..�tl- --........ No.4....3 FEE........................ Uispsal Works Tontrnrt' nVprrmit Permission hereby granted.......-..................--••-• "_ .es...... --•- -L--S--�..G_�._�_._.._........._...................... to Construct or Repair ( ) an Indiy1dual Sewage Dispos System atNo.. ---••-•.........._................ (� - {fit --== .......... treet . as shown onZa;p ' tion or Disposal Works Construction Permit No.:_.. :___ ......_ D �._ ._.. _..�.�.......................--•....._•--- •. .. .. .....• ....._.... cS -------- Board of Health DATE.__...-• - ---------•--•---•----•-........... FORM 1255 A. M. SULKIN, INC., BOSTON �`� N N /1L.//QY ��+a uM FvurTiA1 oe 0 T Z. �. \ D \, #� 0'19 �. N U 7` z Z Q �t'O pew 95N /7 / �p _ncN.p , /q(y� e / . v SUE (42 �dAllN� 1 RSE No.1 095i 0_ ?;LEGEND EXISTING SPOT ELEVATION Ox0 �tHOf INQ CERTIFIED PLO'1° EXISTING CONTOUR ——— 0 FINISHED SPOT ELEVATION o ROBERBRUC T. FINISHED CONTOUR O ELDRED ;e w d a t APPROVED , BOARD OF HEALTH. ' DATE AGENT SCALE,!.. `' DATE.,.� LOREDGE ENGINEERING Ca /N f Y. CLIENT i CERTIFYTNAT THE ':.PROPOSE: EGISTEREO EGISTERED JOB N0; ..$ :BUI0;fNO� $H i�fN ON :THIS P.LAt� K CIVIL LAND CONFORMS: TQ THE ZONING L=A419S E N G I U R V DR.B Y E E R E I Y� 12 MAIN STREET CH. BYt. `Y1 a c- O 0 0 C T . Nn rn zi Ib o N ate _ �0 FR Fly y 7 co C tk T A � � C ® ! • •O �• a ; - o.A �.�� ` � \. ► ♦ • • e e Cl < -� � ,: � `I H y � p � o �` f` ° e o e � • . '. �p rar •' � C O � O t � . rh rkj� y v► A4 � I ,i � � (1► � Z (` N � �' � (T� � y .�, � i" r X y �0 0 � o i • �' �, PIB r J �{ i � .� 4p cl 3 40 s 40 A N 30 C y v 1/1 N ,A p � 4 d � — Z 42 - � C� � `� �� -�• ?: v � .. � { T � �I� 1 ..�.____ _ � A 4F COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PR-OTECfiieON A b a UEC 0 3 2002 I _ i L iEA,'.Tli DEFT. 3 TITLE 5 OFFICIAL'INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION rr MAP I�'�P Property Address:44 Renoir Drive Osterville PARCEL, Owner's Name: Mr.Hegerty Owner's Address: ACT `Z2• Date of Inspection:9/21/02 Name of Inspector: Timothy Lovell r Company Name:Accurate Inspections Mailing Address: 550 Willow Street W.Yarmouth,MA. Telephone Number:508-771-3700 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(31.0 CMR 15.000). The system: x _Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signatur Date: 9/21/02 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system 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. Page 2 of 11 cs OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:44 Renoir Drive Osterville Owner:Mr.Hegerty Date of Inspection:9/21/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: _N/A 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. N/A 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 infiltration 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: _N/A 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: N/A_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: +� Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:44 Renoir Drive Osterville . Owner: Mr.Hegerty _ Date of Inspection: 9/21/02 C. Further Evaluation is Required by the Board of Health: _N/A 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(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _N/A_Cesspool or privy is within 50 feet of surface water N/A_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: _n/a_ 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. t _n/a The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _n/a The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. n/a_ 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: Page 4 of 11 s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:44 Renoir Drive Osterville Owner: Mr.Hegerty Date of Inspection:9/21/02 System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _x_Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _x_Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _x_Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool x_Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow _x_Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ _x_Any portion of the SAS,cesspool or privy is below high ground water elevation. _ _x_Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _x Any portion of a cesspool or privy is within a Zone 1 of a public well. _x Any portion of a cesspool or privy is within 50 feet of a private water supply well. _x 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.] _Yes (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`yes" or"nd'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 H 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. t LD Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGRDISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:44 Renoir Drive Osterville Owner:Mr.Hegerty Date of Inspection: 9/21/02 Check if the following have been done.You must indicate'}es"or"no"as to each of the following: Yes No _x_ _Pumping information was provided by the owner,occupant,or Board of Health _x Were any of the system components pumped out in the previous two weeks? _x _Has the system received normal flows in the previous two-week period? _x Have large volumes of water been introduced to the system recently or as part of this inspection? _x _Were as built plans of the system obtained and examined?(If they were not available note as N/A) x_ _Was the facility or dwelling inspected for signs of sewage back up? _x _Was the site inspected for signs of break out? _x_ _Were all system components,excluding the SAS, located on site? x_ _Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bales or tees,material of construction,dimensions,depth of liquid,,depth of sludge and depth of.scum? _x _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 _x _Existing information..For example,a plan at the Board of Health. Owner had previous inspection x_ _Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) 1310 CMR 15.302(3)(b)J Page 6 of 11 u OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:44 Renoir Drive Osterville Owner:Mr.Hegerty Date of Inspection:9/21/02 FLOW CONDITIONS RESIDENTIAL 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 or no):_no_ Is laundry on a separate sewage system(yes or no):_no [if yes separate inspection required] Laundry system inspected(yes or no):_n/a Seasonal use: (yes or no):_no Water meter readings, if available(last 2 years usage(gpd): Sump pump(yes or no):_no_ . Last date of occupancy: COMMERCIAIA NDUSTRIAL n/a Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgk etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): s GENERAL INFORMATION Pumping Records Source of information:Pumped last by AB Canco 9/20/00 1000 gallons 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 X Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool —Overflow Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative 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: 9/2/83 per asbuilt x Were sewage odors detected when arriving at the site(yes or no):_no_ Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) . Property Address:44 Renoir Drive Osterville Owner: Mr.Hegerty Date of Inspection:9/21/02 BUILDING SEWER(locate on site plan) Depth below grade: 3' , Materials of construction:_cast iron x_40 PVC other(explain): Distance from private water supply well or suction line: s Comments(on condition of joints,venting,evidence of leakage,etc.)` No evidence of leakage ioints seem to be tight SEPTIC TANK:_z (locate on site plan) Depth below grade:_2' Material of construction:_x— — —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:' 1000 Gallons Sludge depth, 3" Distance from top of sludge to bottom of outlet tee or baffle: 2'10 Scum thickness:' 1" 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:_14" How were dimensions determined: in the field tape measurements_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tank is structurally sound,no evidence of leakage,liquid levels are at invert out,pump every 2 years for maintenance. GREASE TRAP: n/a (locale 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.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)+ Property Address:44 Renoir Drive Osterville Owner: Mr.Hegerty Date of Inspection:9/21/02 TIGHT or HOLDING TANK:_n/a_(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:_x (if present must be opened)(locatte on site plan) Depth of liquid level above outlet invert:_0"_ 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 solid cane over liquid level at invert out no evidence of leakage D box looks to be level PUMP CHAMBER: n/a (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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:44 Renoir Drive Osterville Owner: Mr.Hegerty , Date of Inspection:9121/02 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type _x_Leaching pits,number:—I— Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields, number,dimensions: Overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil;signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): No evidence of hydraulic failure,Liquid level is 3-_1/2' no scion line to indicate level has been any higher,no dam soil,vegetation normal CESSPOOLS:_n/a_. (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: n/a (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:44 Renoir Drive Osterville Owner: Mr.Hegerty Date of Inspection: 9/21/02 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. Front of Home 22� Drive Way i t ,1 t si Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:44 Renoir Drive Osterville Owner: Mr.Hegerty Date of Inspection:9/21/02 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: _x_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: Observed property next door this house is located on a hill bottom of hill is approximatelvl'S'to 18'deep with no indication of ground water bottom of leachingpit is 10'bottom of hill is 5'below that with no groundwater ' b S MAP: - ASSESSOR TEST HOLES LOGS " NOTES: '�. PARCEL: � FLOOD ZONE: A/oi . SOIL EVALUATOR: 1 W l 1 comply with Title V Town f Barnstable Board of �. WITNESS: .��((� 1) ..The installation atian shall ca p y w><t a and o 0 4 R FERENCE: -T PL-P — C � ' E � � , ���� DATE: l� 1 ( Health Regulations. 2 PEROLAT ION. RATS=: L• G 1 2)- The instiller shall verify the location of utilities,sewer inverts and septic -- — components prior to installation and setting base elevations: p p g j �-1----- 3) .All gravity septic piping to be 4 inch Sch 40 PVC at 1/8 per foot.The first TH-1 _TH-2 'beez e!; two feet out ofthe dbox to the leaching. L � 4) This plait is not to be utilized for property line determination nor any other j q 10 „ t i purpose other h than the proposed h syst em installation. D D , I 5) All septic components must meet Title V.specifications_ ` ') 6) Parking shall not be constructed over HI septic components. Proposed units r 5 LOCATION MAP � are H2O. 7) The property is bounded by property corners and property lines. yw 8 The o owner shall review designconsiderations to approve of total Ito fl ) �'" design flew and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed a royal of the design flow b the owner. � PP . �. : g Y 9 The existin leach it shall be u and filled with material per Title V ) g P pumped abandonment procedures. Those within the proposed SAS shall be removed P P Po 1 along with contaminated soil and replaced with clean washed sand per Title V s Pecs lines crossing the 10)System components to be 10 feet from water tine. Seweres Gros rig water line shall be sleeved with 6 inch SCH 40 PVC with ends grouted. SEPTIC SYSTEM DESIGN . . �` . . I 1 If a arb� a rider exists rt�s to be removed and is the responsibility of the ) g gg FLOW ESTIMATE owner to,ensure such. E . 12)The water line is to be relocated as shown per service provider specifications. BEDROOMS AT GAL/DAY/BEDROOM •3.i9GAL/D Y -Requested Variances, SEPTIC TANK Title V Section1:5.211 GAL/DAY x 2 DAYS GAL SAS to foundation..`20 feet required, lA feet proposed, �foot variance i 1w ? �USE ,fie GALLON SEPT I C TANK 94 _ - _ with 40 mil 1 liner installed between SAS and foundation. poly SOIL ABSORPTION SYSTEM t ry 1 rr r AREA G J 4 f,� �4 Z"� BOTTOM AREA: )(` o �.. /10 , F y t s \ r ,- SEPT 1 �; _.. SYSTEM SECTION ZY \ 6aC - ntbw - _ - ` X SIC i. . 1 r ti Z o a GAL01N� [DOD q ► Q� �(�(�j� (�.� b �`�4 � '` � c � i SEPTIC TANK L t,t Til„� N CF dC�b No , c DNAD MAc. w E. .oN m SITE AND SEWAGE PLAN No.1 �66 ti , 1 T 4 y TPE0( t 1V VWD`✓ 1,TP10 1 LOCATION . � rrr� : -* °. PREPARED FOR : SCALE: 1 .6 t�AV I D B . MASON RS DATE. 1t z )BC ENV I ROHMEWrAL DESIGNS 'EAST SANDWICH . MA W DATE HEALTH AGENT � ( 508) 833-2I77 I