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Home My WebLink About0021 ROBBINS STREET - Health �l ��6�1�; �S�- �:��r-Zl.-� �yl - �a� m / 7 F i ,; Fee yicoryt- �t�r��i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes -arl-lu—BLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Migpozar *pgtem Cow6truction Perron Applicat�forermit to Construct( )Repair(K)Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lo[No. `"Z Q,D5Z 6105�T Ow er's Name,Address and Tel.No. Mgr- - ; K EL-L_ENEC Assessor's Map/Parcel 4 1 17-9 10-7 &SSi us '!E-1"F DS L� Installer's Name,Address,and Tel.No. gZ8--SS'2 J D igner's Name Address and Tel.No. ��z+sc�, I"1ilGAL t_tS T�2 �i "LL-,vA� Type of Building: f A� Dwelling No.of Bedrooms g Lot Size f 116 sq.ft. Garbage Grinder lam Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures /� Design Flow 33® l�AL1,&kAt , gallons per day. Calculated daily flow SYS gallons. Plan Date AUCo 28? t99S Number of sheets 2- Revision Date Title 'S iTE?c.Atj ., FQ Cw()6 D SEPTIC. '0 eG epye Size of Septic Tank 15M 6ALL.D LA Type of S.A.S. L.EtaGt-El LAC`s `6F_0 Description of Soil 0 -2 '' CV-US to cD 5� - fir` LA A wt�( SA kl D ' ZZ" MED SAND \/d+11-1 Sore G S1 4T 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 Environment Code and not to place the system in operation until Certifi- cate of Compliance has been issu b thi Board o alth. Signe Date Application Approved by $9�_ Date Application Disapproved the following reas s or Permit No. Date Issued / A Fee THE,COMMONWEALTH OF MASSACHUSETTS Enteredincomp�uter: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS �-' for i� o ar gtem Construction Permit ��rtcatton � � p Application �Permit to Construct( )Repair(K)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ? �A5 6 I NS Z T O er's Name,Address and Tel.No. a��3 K�L_LEVAC2 Assessor's Map/Parcel ,, / Z9 10_7 24�1 xa s ST (y, 1 L L. Installer's Name,Address,and Tel.No. <lZS^S52`� D igner's Nam Address and Tel.No. v k-L�v 'T ?A4LY_E;C_ eok-G> C�-M2-N/I LLC Type of Building: Dwelling No.of Bedrooms 3 - Lot Size 16� a sq.ft. Garbage Grinder Other Type of Building - No.of Persons Showers( ) Cafeteria( ) Other Fixtures ' l 2 Design Flow 330 AA gallons per day. Calculated daily flow 3�J gallons. 1 Plan Date A L)& ?Z 113:% Number of sheets Z- Revision Date Title S l Tr-- ?,-A(,J I 2.Q P06 EQ 5 G:Pn(- U 406 0 A9e Size of Septic Tank 1 S Q'7 C1 t LQ t a - Type of S.A.S. L,EAc Description of Soil G '2 C_ZU5 L1 o S�N G Z -' a �.bA rvl� ��\I.a 1) ZZ" MCC) SA"D VJ ii- A SGM E SILT 22" —9�." CbAZS€. Nature of Repairs or Alterations(Answer> en a r 'cable) ' Date last inspected: Agreement: ,be 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 Environment Code and not to place the system in operation.until Certifi- cate of Compliance has been issu d b th' Board o ealth. �� q Signe o /1 Date IV Application Approved by `� � � � Date Application Disapproved for the following reasons K t Permit No. s Date Issued -5.P I �-------.-- w THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS s Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (;1O Upgraded( ) Abandoned( )by at l D`7 Zoa s t S GT 05 jE a_V I L•-L ben constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system ill functions as designed. Date 9 ° ./ - I Inspector No._� Fee r v THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Xt!9po!5a1 *p5tent Con5truction Permit Permission is hereby granted to Construct( )Repair(X)Upgrade( )Abandon( ) System located at 10-7 (_ore)"! ST D�Tncu( L_L E^ and as described in the above Application for Disposal System Construction Permit.The applicant recogni es his er duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction mu t be o ted within three years of the date of tMIIQpe �*t. Date: Approved by 0 �� I 9 o22S3 I _S,Ab 5XIST. CrARACG TO / t I . pC RernovEp / I. N �` (P It N / 1p. o� W IN. AepX Z IV g�. = tv Houg� S,Aar uo / o 0ELI m IIN co/Q. / a11 I � M IN I / co 0 %v 131 195 .03 o r PLAN VIEW Scale: I"= 30' r DEEP HOLE TEST NOF, Date Aug.21, 199 8 ply Engineer:S flivan Engineering Inc. SUL IVAN Depth: 96" N0.29733 Class I Material CIVIL { Ground Water at 8.0' Elev.5.4 ! ' Index Well MIW 29,Zone C l O. Adjustment 2.8 Adjusted Ground Water Elev. 8.2 �I19M TH-1 EL. 13.4 0 CRUSHED STONE SITE PLAN 21 A LOAMY SAND PROPOSED SEPTIC UPGRADE s" 6 MED. SAND AT w/SILT 107 ROBBINS STREET coAa5E SAND OSTERVILLE, MA 9 b . FOR ROBERT F KELLEHER SCALE I"=30' DATE: AUG.28,1998 SULLIVAN ENGINEERING INC. SHEET * I Of 2 OSTERVILLE MA NOTES LWatertupplyForThis Lot is Municipal Water. DESIGN DATA 2.Location of Utilities Shown on This Plan Are Approx.} Single Family-3 Bedroom At Least 72 Hours Prior to Any Excavation For This With no Garbage Grinder Project The ContractorSholl Make The Required Daily Flow=1 I0 x 3= 330 GPD Notif icotion to Dig Safe(1-800-322-4844) Septic Tank:330 GPD x200%=660 GPD 3 The Contractor is Required to Secure Appropriate Use 1500 Gallon Septic Tank Permits From Town Agencies For Construction LEACHING AREA Defined byThis Plan. 330 GPD/0.74=446 SF Required . 4 Install Risers as Requiredto Within 12 of Finished Grade. Bottom Area= 15'x 30' =450 S.F. . t' 450 S.F.Total Provided 5.All Structures BuIried Four Feet or More or Subject' LEACHING BED DESIGN to Vehicular Traffic to be H-20 Loading. fi Septic System to be Installed in Accordance With All Pipes to be Schedule 40.PVC P Y Perforated With Capped Ends.Use 310 CMR 15.00 Latest,Revision And The Town of 4-4"Distribution Line in Leaching Barnstable Board'of Health Regulations. Bed in a 15'x 50"Washed Stone Field as Shown H OF 7. All Piping to be Sch 40 PVC SULLNAN Ito.29M y CIVIL F.G. F.G.15.2 3fE OZZ See Note 4 /Q A 13. Inv. 12.8 A 13.6. 1500 Gallon 13.4 `� 13.2 . Bot.E1.12.2 13.0 Bedding as 4 Per Title 5 10 10.5! 10' 10' 12 Bottom of Test Hole El.5.4 Adj,Ground Water E1;8.2 DEVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM Not to Scale ' Finish Grade x ' 0 er Compocted�Fi ll Fabric ro ' Pea Stone 0 4!'0 Perforate 3/4°-1 1/2°Double PVC Pipe Q) Washed 3-0 3-0 3-O 3-0 15'-0� CROSS SECTION OF LEACHING BED R.Kel leher Not to Scale SHEET 2 of 2 • 1 h _ , s_- l"� D F � �� yowl A•�'$ �,�„ ' r V �. � �° � � 11� � a - � rp, # TOWN OF�BA—RNSTABLE LOCATION I/14.S J 1. SEWAGE# VILLAGE OS I Q,�Ut� ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ( §W '9�0 LEACHING FACILITY:(type) 1 e, (size) NO.OF BEDROOMS II_ OWNER Q, V1l,r PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED B M .) . -I a, ► Fro ` A GAr4C L O O A3� 30 a as as 3 s �s TOWN OF BARNSTABLE LOCATION 0 - S ST SEWAGE # RSs Vr LAGE 05- E G ASSESSOR'S MAP &LOT I�'Z- J INSTALLER'S NAME&PHONE NO. 19,110-cG.L is-- SEPTIC TANK CAPACITY JSOO GAL — A OR0 LEACHING FACILITY: (type) (size) ��, 3d NO.OF BEDIWOMS a " BUILDER OR OWNER PERMPFDATE:sS T,9 - 11g4k—COMPLIANCE DATE: 3 -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 w` w ao T' I aT . w 0 a LOCA N SEWAGE PERMIT NO. YIlLAGE INS LLER'S NAME ADDRESS B U f-1 D EEjk OR OWNER DATE PERMIT. ISSUED DATE COMPLIANCE ISSUED �µ ;,�G.< ..... ]-V � � ;. 1fI III r� _ 1 �� ' , �. \l� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE.5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A . CERTIFICATION Property Address: 21.Robbins Street:. Osterville,MA 02655 Owner's Name: Maureen Kelleher Owner's Address:. Date of Inspection: August 16, 2012 Name of Inspector:.(Please Print) James M. Ford Company Name: James M Ford Mailing Address: .. P.O.B6c 49 Osterville,MA 02655-0049 Telephone Number: :' (508)8624400 CERTIFICATION STATEMENT : L.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:' ham a DEP approved.system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes ds Further Evaluation by the Local Approving Authority as n Inspector's. Si Signature: Date: Au ust 17 2012 g , 8 . The system inspector shall sub ta'copy of th s inspection report to the A.'pprovin.. 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 sentto the system owner anI.d copies sent to the buyer,if applicable,and.the approving authority: ' Notes and Comments ""This report only describes.conditions at the time'of inspection and under the conditions'of use at that time.. This,inspection does not address how the system will perform in the future under the same or different conditions of use: Title 5 Ins ection Fonn 6/15/2000 page 1 v� Page 2 of 11 • A OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Robbins Street Osterville•MA Owner: Maureen Kelleher Date of Inspection: August 16, 2012 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated,below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,_upon completion of the replacement or repair,as approved by the Board of Health,will pass.. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking.and if a Certificate of Compliance indicating that the.tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced .ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed ND explain:.. 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Robbins Street Osterville,MA Owner: Maureen Kelleher Date of Inspection: August 16, 2012 C. Further Evaluation is Required by the Board of Health:' Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303 (1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic.tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. - The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water.supply well*". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility,and the.presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other . failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3. Page 4 of 11 0 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 21 Robbins Street Osterville,MA Owner: Maureen Kelleher Date of Inspection: August 16, 2012 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool . ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool i ✓ Static liquid level in-the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool . ✓ Liquid,depth in cesspool is less than 6"below invert or available volume is less than% day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s): Number of times pumped _ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone'1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia . nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either"yes or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.. The owner or operator of any large system considered a significant threat under Section E or failed under.Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 21 Robbins Street Osterville,MA Owner: Maureen Kelleher Date of Inspection: August 16, 2012 Y Check if the following have been done:.You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were.any of the system components pumped out in the previous two weeks? ✓ Has the system-received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? _ Were as built plans of the system obtained and examined?(If they were.not available note as N/A) Was the facility or dwelling inspected for.signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ Were the septic tank manholes uncovered;opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? '✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 4 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 21 Robbins Street Osterville.MA . . Owner: Maureen Kelleher Date of Inspection: August 16, 2012 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Number of current residents: 0 Does residence have a garbage grinder(yes or no): N/a Is laundry on a separate se*age system(yes or no): N/a [if yes separate inspection required] Laundry system inspected(yes or no): no Seasonal use(yes or no): no Water meter readings,if available(last 2 years usage(gpd)): Unavailable' Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _gpd Basis of design flow(seats/persons/sq/ft etc.).- Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe):. GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): If yes,.volume pumped: eallons.--How was quantity pumped determined? Reason for pumping:. TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow.cesspool Privy Shared system(yes or no).(if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe):- Approximate age of all components,date installed(if known)and source of information: Date of installation 913198 per as-built card Were sewage odors detected when arriving at the site(yes or no): No 6 �a Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Robbins Street OsterWlle,AM Owner: Maureen Kelleher Date of Inspection: August 16,2012 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.):. SEPTIC TANK: ✓ (locate on site plan) Depth below grade: . 12" Material of construction: - ✓ concrete _metal _fiberglass _polyethylene 'other(explain) If tank,is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1500 gal. H-20 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: .10" How were dimensions determined: Measuring stick Co mments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.). The tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage Recommend steel covers be installed unto grade: The tank is in the driveway. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: . Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 R OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Robbins Street Osterville. AM Owner: Maureen Kelleher Date of Inspection: August 16, 2012 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of-alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,.any evidence of leakage into or out of box,etc.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 4 , 8 .,. Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL SYSTEM"INSPECTION FORM PART C SYSTEM.INFORMATION (continued) Property Address: 2.1 Robbins Street Ostemille,MA Owner:: Maureen Kelleher Date of Inspection: August_16, 2012 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. Uocate where public water'supply enters the building. y 4 4 . n Fw �oAT' ; a3 30 4 e 10 y'• Page 11 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 21 Robbins Street Osterville:MA Owner: Maureen Kelleher Date of Inspection: August 16, 2012 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 12+/- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe-how you established the high ground water elevation: _Using Barnstable topographic and water contours maps, the maps were showing approximately 12 +/-to ground water at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed.as of.the date of inspection. This report is not a warranty or guarantee that the system will fxurction properly in the fixture. There have been no warranties or guarantees, either expressed, written or implied, relating to.the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 No........ Fa$ THE COMMONWEALTH OF MASSACHUSETTS �-� BOARD OF HEALTH ki Appliration -for Biipuiittl Worko Tonstrnrtimn Vrruift Application is hereby made for a Permit to Construct ( ) or Repair ( kran Individual Sewage Disposal System at: Ron. - .t................ c -� .�. 2 orLot No-•----...---------------------------------------- aS� -Address .•-. - . ............•...••••......-•............. W Q) Owner �.... .... ... ......;�. f Address a Ins er Address UType of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building ............................ No. of persons--------------------------- Showers ( ) — Cafeteria ( ) Other fixtures .. .--------------------- ----------------------------- Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity-_ li__--___-_gallons Length---------------- Width-.-_--.......... Diameter_........__..... Dept .__......_...... x Disposal Trench—No. ................:.... Width...............----- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area.........._.......sq. ft, z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY.......................................................................... Date........................................ Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water..------------------- ;I, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...............---....._ P -------------------------------------------------------------------------------- -........................................................................... 0 Description of Soil----------------- ----------------------------------------------•----------------------------------------------------------------------...--•-•......------------------. W ------------------------------------- ............-........................................................... -- -- -- - - - ------------------------ -- U Na re of Repairs or Alte Mons—Answer when appli b � Y .:.�� ---------------------------------------- -e- L ............................. greement: 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 bp n 'ssued bly the boardaha �7 '7/Signe ----- C ud1. - .._cv- _97 .!-�ll p Date Application Approved BY - •• ---••--•--•----- l .........7 Date Application Disapproved for the following reasons:......................... ....................................................................;._............... ...................................•-----••------•------------.......----•--•----------...-•-------------•--------..........--------•-•-----------------....----•------------........---•-----.....-•-•- Date PermitNo......................................................... Issued...................... ................................. Date ------------------------------------ ---- - -- J No......................... '_ / FEE.��........:............ THE COMMONWEALTH OF MASSACHUSETTS ��` ,tee, BOARD .OF HEAL H t' Appliratinn -fear Uhipoiitt1 Nforkii Ton,itrnrtimn Vautit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: ............................................................ .:............... ��`�'l �.. �-.... ........................................................... . :_:.. / Locations Address or Lot No. ........... r!1 Owner.............-rL".l-...-. -..•.----•---•----•----•-----.. _ .!�� !/J. /yJ./fir -•---------•--•----ram•--------- ------------------------------- 7 ! E__ Address Inst Address Q Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms-------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) a, Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) al Other fixtures --•---------------------------- -- Design F)ow__________________________________ _________gallons per person pe-r• day: Total daily flow................___.- g W -------•--------•------ Mons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width.------ ........ Diameter__-.....-..----_ Depth---------------- x Disposal Trench—No. .................:.__ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet-------------------- Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by----------------- ........................................................ Date------------------------------------... Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water...-.----.-.---.-.---. - G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--.--.__-______----_-.-. 94 ----------------------------•---•-----------.......................................................•-------•-----•----------------•-----------•--•--------- ODescription of Soil---------------------•-----------•-------------•-•-•--•---------••--•-••--•-----------------------.._.._...........-•-•----..__... ......... -------------------- x W ---------------- --------------------------•----•-•------------•----------------------------------------•---- = r --------------------- ----- V Nat re of Repairs or Alterations—Answer when applicabl .. e-�//:._. � ^.r f`�.!�. .... �_______________ r -.. r. / `- �1 r�l ? is J.:/ .-�. . �,� _f 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 beCissued by, the board of he It �Sign r__.,!/ ----_---`_ ��----�-�1^`�-?-=J`-z`'�-"-'-`-�-�--... _ /r ---.^-. Dat Application Approved By----- �`', j d�✓i11.- V ---------------- ------ ----2Date Application Disapproved for the following reasons:......................... -----•-------••---•--•-----•-••-----------------------------•----------------- ----------------------•--------------------------------------...........-•-•-•----...._...------------•-•..-•--•--•----•----•-----•-----------------•-----------------------------........ .............. Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD C�Jf HEAL H .......................................... / Trrtifiratr of Tompiinurr THI.'-I TO CET IFY,,'that the, nd•.v,id gal Sewage -'isposal S-%stem constructed ( ) or Repaired by ... .. (.. l._.i J G �t .... '�' ''Q�` -- ------ f r,/ ` I st�Q+talle�rrx at. _------ /� - d .. ----------------............ . ......S_/............................ has been installed in accordance with the provisions of A /i44,e)XI o The State Sanitary Code a described in the application for Disposal Works Construction,Permit No... ........... ...................... dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE �� Inspector C-6p�__ ------------------------- 0.7� THE COMMONWEALTH OF MASSACHUSETTS BOARD I7 HEALTH �2.. .......7.1 .................................................................. No......................... FEE.......................... Dinpaiial- orks C�pniitrnrtivn mit 3 ` Permissi n hereby granted, -- r (✓1_� - ------•----71.�, .1 ,�'1 -----------------------•--. to Const ft r) or R pai n Individual Sew.a e D•s o al System �'^ i t at No. ra Street / 1 2 as shown on the application for Disposal Works Construction Permit No..................... Dated---. ----------___.................... �G ' >_. ..: = �-7� Boar fag w�c k, DATE.,.. ---•••-- ......-•--------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS TOWN OF BARNSTABLE LOCATION .S S% A SEWAGE VILLAGE Os✓CiwlI G ti ASSESSOR'S MAP & LOT1y/-_j 1 9 INSTALLER'S NAME&PHONE - SEPTIC TANK CAPACITY J S oo Cp aI. /!-0l0 LEACHING FACILITY: (type) G� (size) /Jd r NO.OF BEDF40OMS c� / / / ` BUILDER OR OWNER _ /11•eS.�yh�rT 17 I/l' - PERMITDATE:�S '�T,1_— l�g�-COMPLIANCE DATE.: .3 Separation Distance Between the- Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well land 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}00 feet of leaching facility) Feet Furnished by q e a 36� 31 ' 1 �a Lam% 33` - ... 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D - v Z o _r it a ANDERSEN CM46 o a6 1/aM1e 53 a/a' g o m O 3 3 , J W U. c gVxD g� �� CAP@ C®o RErwOpSt,)NO, LLC. �m =1nflpy RICMARD AVERY s MASMpCC, MA 02649 CELL: (,008) 9SQ-7373 NC• TN-� MAZUR -RESIDENCE , 21 ROBBINS STREET, OSTERVILLE MA N m .. ... 3 BAYBER S TERVIL 02632 LAN FLOOR PLANS N w PHONE: 508-77 i M 1 O FAX 50155 c.,)v r 3 o o 2-5�