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HomeMy WebLinkAbout0108 ROBBINS STREET - Health (2) 0$ Robbins Street Oste.'fle _ A 142 121 n w, V t A ° a r : m ° ° ° - ° c -0) THE COMMONWEALTH OF MASS'ACHUSETTS BOARD OF HEALTH TOWN ....--....OF..........HYANtVIS _... .... .. ...... ................................................... Appliration -for Bitiposal Works ( omitrurtion runiit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: Yarmouth Road Lot No. 6 --------•--•-----•------------------••---...-•--•-------....---------....._....---•.....-•-----••- -•-------•-•----•-------•--•--••-----•.......-•---•••---•••••••--•••--••-----•---.........------ �— Location.Address t JQ 1&JA J asl"" `3 �'►ll� food., l`O ' ('c2: D_eA.)/vi f,_..OQ Owner Addre Install Address Q Type of Building Size Lot.9.,7 0 t....____._Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) per-, Other—Type of Building __Off ioe-_------- No. of persons.........2 Q_____________ Showers ( ) — Cafeteria ( ) P4 Other fixtures ...................................................... W Design Flow-----15..................................gallons per person per day. Total daily flow-------------------aQ0_................gallons. W Septic Tank—Liquid capacityl0 __ U-gallons Length __6��. Width-4.�aQ��- Diameter_____ _________ x Disposal Trench—No- ____________________ Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No-----1............. Diameter.12:'.-0'-_. Depth below ;jet_6_�._-0"._.__ Total leachin area-_..339-----sq. ft. Z Other Distribution box ( X) Dosing tank ( ) ® '� Percolation Test Results Performed byCape...CQd...S.0 Vey...Cgn u_lt4AtEDate__MArgll--:15-,.--19-7.7 a Test Pit No. 1----ZOO....minutes per inch Depth of "Pest Pit 12.j o.'.... Depth to ground waterno...water. r14 Test Pit No. 2................minutes per inch Depth of Test Pit---------------------- Depth to ground water------------------------ ------------------- --------------•--'------------....................................................................... ..... Description of Soil....... 0_!--1.-Q'-.-fill-•materiall__•1_.0_'_-2-.-0-'---loam•-.&_-sub- .�P�c" OF.- sQa_1.%-- 2_._0'_-7_, Q_'___ooaree---gravel- 7.-Q '-8-.51----clean-�---white---------- 8. 5. - 9 5:--- _Cpare._.gravel;_--9_,-5_'---12.,.0-'.---clean-.white__•sa- RErvwiCK ym M ____ S� .d�-_-- z__ '_ -_-e_._ ' U Nature of Repairs or Alterations—Answer when applicable.-_______ ______________________ _________ _____________ ��,------ HAPMA4---- --------------------------------------------------------------------------------------------------------------------------- No._27664 Agreement: �`� /207 The undersigned agrees to install the aforedescribed Individual Sewage Disposal Sys em in UP= G' the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place t m in operation until a Certificate of Compliance has been issued by the board o 4ealth. Sied .. ....-- .. --------------• ---------•-...... Date t t 7- -APPlication Approved BY Datea Application Disapproved for the following reasons------------------------------ ----------------------------------------------------------------------------------- .............................................•----------------...-•------••••••••-••......-•••-•••-----••...----•-------•......._......-••--•--..••-••----•----------------•-..---.•-•--------------••••- Date Permit No........................................................ Issued..._ ----_--2 ` 7 --------------••--•••-•...---•- Date -------------------- JI 04 No.......... .. `y►`.r FEE.........0 ..... .— - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . TO_WN ........O F HYANV I S... ................................................... , Ap.p iratilin -fear 4%ipoiial Works Tomitrurtintt Vrrtltit Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal System at: r Yarmouth Road Lot No. 6 ._..----••-------------------------••------•----...-•-------•-••-----------------•-----...--•----- -----------•-----------•------•-----•--•---------••--•----•--••••-•--------------------------•--. +, Location-Ad dr ss + or o.CX " ! .r►e..---..---N-1N�..................!- -S-""!�fi` '1��.4.k , '---- �'------.�'rax-_ Owner Address Installer Address UType of Building "t Size Lot_-g_07©3t.._..._..Sq. feet �-, Dwelling—No. of Bedrooms____________________________________________Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building __office________ No. of persons..........2 0__....._.... Showers ( ) — Cafeteria ( ) 0.i Other fixtures ______________ d --- •-••-•......... --...-•••---•--•---••------------------•-------......•..... -- � W Deslgn Flow......__15.................................gallons per pert son per day -Total dai y.flow_._.._______________300----------------g allons. P4 Septic Tank—Liquid capacity ZDDOgallons : Length__S__..__...__ Width_-4_ lliameter---------------- Deptit_-_5.-_" .. r , x Disposal Trench—No- ___________________ Width............________ Total Length------------------_ Total leaching area-----------_-______sq. ft. S-e�age Pit No------I------------ Diameter._12.°��_`_ Depth below inlet_6_'.-0" Total leachin area._-_.339_._.sq. ft. z Other-,- istribution box ( Dosing tank ( ) Q.A— /0G P, __ai�on Test Results Performed byGage.••Cad---SurVey---CoTiSultant�jate__.MarCh-_-].5_ 9977 a -••- est Pit No. L____2 t_Q__minutes per inch „Depth of Test Pit �-2_�0_'... Depth to.ground water no-:wAter G14 st Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water -____•-••••------------------•----- SK_�F.!1Zq -Q••..,_Aescription of Soil_ __:_O.0°v4 - 0 ', f ill material; 1_.0'-�2.0 ' loam---&_--sub 3s9� -------, - ----•-- .......... z- - ---- ------- y x Soil-----2,t?'-�7 0' coarse vravel.r 7 0° 3.5 ' clean,- white RENWICK c� U ---- -------- - r„ .....sand-;-- 8.�'--9-•-5°___coarge gravel,- 9._5-¢---12.0 ' clean-_white Sa .. . B __ ----- >CIAProtA - w V Nature of Repairs or Alterations—Answer when applicable_________________________________ _ J _ .p-o _2765q_o . ..................................................... ---------------------- --------------------------------------- /........ 41GfS TV: R� Agreement: !��/ FSS�ONALENG\ �2L197 The"undersigned agrees to install the aforedescribed Individual Sewage Disposal System in ac ith :_,the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of h alth, Si ed. ----------- -- 4-_ Date Application Approved By j � .J__-A.v x Date Application Disapproved for the following reasons: ---------------------------------------=--------------------------------------------------------- ..----•--••-••--•••••---•--••...••------•---------------------•-•- ------••---•-•••---•------••••-•-••....-•-••--•••••--••-------------------•-•.....-----------•---••---•-••...------------..........--- Date PermitNo---------------------------------------------------------- Issued............................... ................... Date L.` V THE COMMONWEALTH. OF MASSACHUSETTS qq i BOARD OF HEALTH ... OF_ Tatifirate of To mpliana THIS IS 4T0 C R-:TY Y, Tha he In i idua Sew e Disposal S stem constructed ( or Repaired ( ) b .... • ---- ---------------------------- ' l tape J r has been instalfied -accordance with the provisions of A 'I of The State anitary C*- es described in the application for Disposal Works Construction Permit No.. 7...... dated_._--A_ -_7- _,_______________. TFIE• ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS.A GUARANTEE THAT THE SYSTEM WiLC FUNCTION SATISFACTORY. DATE........................................ = Inspector ............................................................. .ti THE COMMONWEALTH OF MASSACHUSETTS `�� BOARD OF HEALT �L% '1........O F........... .. ..................... No........ ....... FEE .... Ritivolittl lullr _q (1,111mit �irti rr 't Permission is hereby granted,,__""._. •... ... •-�. . -•----- - -------------------------- •--...--------••--------•-- to Const uct ( or ( ) an divldual w e Dispos System at No.-.,.. + " Street as shown on the application for Disposal Works Construction e t No._- Dated__ Z�/�.7-- ............. .......... y _�3�. 71- { .gBioarxilHOW.1th �' • TE ----------------------------------------r----------------=---_------ . DA , `FORM- 1255 HOBBS & WARREN. INC.., PUBLISHERS , OF BA RNSTABLE LOCATION God 3 f /�'S s SEWAGE # VILLAGE ®��ew�/! ASSESSOR'S MAP.& LOT zd 4NSTALLER'S NAME & PHONE NO. AP17-alellJ'CO:s)� tVZ-s'-)rPzt1;, ,SEPTIC TANK CAPACITY /4Z?' r 9LEACHING FACILITY:(type) Z / °� ® (size) J ' 0. OF BEDROOMS PRIVATE WELL ORdUBLIC WATE BUILDER OR OWNER DATE PERMIT ISSUED: �r DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 6 43 1 c� 3y `" =l 7 s 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 108 Robbins St. Property Address Cathy O'shana Owner Owner's Name information is Osterville MA 02655 9-18-12 required for every _ page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When fltling out forms A. General InformationL IL on the O�npriii� use only the tab �mputer, �``��\'�� Mqs ��: 1. Inspector V �. y key to move your p '��r JAM ES • v' cursor-do not James D. Sears = use the return Name of Inspector — �" $ =y key. Capewide Enterprises,LLC Company Name v1i'F S INSP��'������`` 153 Commercial St Company Address Mashpee MA 02W Cityrrown state Zip Code 50BA77-8877 S 1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. i am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16..000).The system: ® Passes r ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority .9-18-12 ' spec oes 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 haw the system will perform in the future under the same or different conditions of use. 15ins•11110 Tmo 5 orriew inwectbn Fonn:subwrfaoe sewage olsposal system.Pepe 1 or 17 Sep 1812 10:34p p.2 - Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Robbins St Property Address Cathy O'shana owner Owner's Name information is required for every Osterville MA 02655 9-18-12 page. Citylrown State Zip Code Date of Inspedion 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. Check the box for"yes', "no' or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11110 Title 5 Official Inspection r-mm Subsurrece Sewage Disposal System Page 2 of 17 Sep 1812 10:34p p.3 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal'System Form-Not for Voluntary Assessments 108 Robbins St. Property Address Cathy ashana Owner Cwuner's Name information is required for every Osterville ' MA 02655 9-18-12 page.. City town - State Zip Code Date of Inspection B. Certification (cont.) `. B) System Conditionally Passes (cont.): ❑ 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 replace ❑ Y ❑ N ❑, ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced :❑ Y ❑ N []' ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y [] N ❑ ND (Explain below): 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 151,�s•11110 - TMa 5 08ldel tnspadlon Form Subsurfam Sewage Disposal System•Page 3 of 17 Sep 18 12 10:34p p•4 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U-V 108 Robbins St Property Address Cathy O'shana Owner Owner's Name information is fo required for every Osterville MA 02655, 9-18-12 page. Citylrown State Zip Code Date of Inspection B. Certification (cost.) 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. D) System Fall Lire 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 ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in znspW Is less than 6" below invert or available volume is less than %day flow f'i/S [sins•11110 Title 5 Offidal hopecrion Form:Subeurraoe Sirivage Disposal System•Page 4 of 17 Sep 18 12 10:35p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Robbins St Property Address Cathy O'shana Owner Owner's Name information is required for every Osterville MA 02655 9-18-12 page. CityrTown State Zip Code Date of Inspection B. Certification (oont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Z 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 fecal coliform bacteria Indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ ® The system fails. I have determined that one or more of.the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 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. 15ins-11MO Title 6 OlHdal(nspedlon Fam-Subsurtew Sewage Olsposal System•Page 5 of 17 Sep 18 12 10:35p p•6 z, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Robbins St. Property Address Cathy O'shana Owner Owner's Name Information is required for every osterville ' MA 02655 , 9-18-12 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? ❑ ® 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 WA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): NA Number,of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 15ins.11/1D Title 6 Of irlal Inspection Form:Subsurface Seweae Disposal System•Page 6 of 17 Sep 18 12 10:35p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Robbins St. Property Address Cathy O'shana Owner Owner's Name information is required for every Osterville MA 02655 9-18-12 page_ Citylrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 gal precast tank D Box and two 1000 gal pits Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readin s,'if available last 2 ears usage d 2010-66,000Ga) 9 ( Y 9 (9P )) 2011-91,00OGal Detail: Sump pump. ❑ Yes ® No Last date of occupancy: Present Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR f5.203): GaNtms per day(gpd) Basis of design flow(seats/personslsq.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: ISim3.11J10 Title 5 Of®dal Inspection Form Subsurfeca Sewage Disp osal System•Page 7 of 17 Sep 18 12 10:36p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 108 Robbins St. Property Address Cathy O'shana Owner Owner's Name information is Osterville MA 02655 9-18-12 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA 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 ❑ Prrnry ❑ 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)and a copy of latest inspection of the 1/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): tSins•11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Pape 8 of 17 Sep 18 12 10:36p p.9 Commonwealth of Massachusetts .. Title 5 Official -Inspection Form Subsurface Sewage Disposal System Form-Not For Voluntary Assessments 108 Robbins St. Property Address Cathy O'shana Owner Owners Name information is required for every Osterville MA 02655 . 9-18-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1995 Permit 0 95-951 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below 31 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.): Pipeing is 4" pvc sch 40 Septic Tank(locate on site plan): Depth below grade: 23"teat Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal Precast 1. Sludge depth: 15ins•11110 Tile 6 Offlolal Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Sep 18 12 10:36p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form a o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 108 Robbins St. Property Address Cathy O'shana Owner owner's Name information is Osterville MA 02655 9-18-12 required for every page Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 291 lot Scum thickness 8.. Distance from top of scum to top of outlet tee or baffle 17" Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Asbuilt-Tape Sludge Judge 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 and outlet cover at 23", inlet cover at 8". Tank at working level w/in and out let tee's. No sign of leakage or over loading Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): j 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 (Sins•11110 Titte s otficial Inspenlon Form:Subsurrsoe Sewage Disposal System Page 10 of 17 Sep 1812 10:37p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form -- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 108 Robbins St. ` Property Address Cathy O'shana Owner Owner's Name information is required for every Osterville MA 02655 9-18-12 page. Cityrrown State Zlp Code Date of Inspection D. System Information (cunt.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene [] other(explain): Dimensions: Capacity: gailons 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 t5ns.11l10 TWe 5 official Inspedim Forrm Subsufaw Sewage Disposal System•Page 11 of 17 Sep 18 12 10:37p p•12 g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 108 Robbins St. Property Address Cathy Ushana Owner owner's Name information is required for every Osterville MA 02655 9-18-12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box (if present must be opened)(locate 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.): D Box at 38"below grade w/two line's out Box is clean and solid. No sign of over loading or solid carry over Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins 11/10 rdle 5 Official Inspection Form:Subsurface Smge Disposal System•Page 12 cf 17 Sep 1812 10:37p p.13 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Robbins St. Property Address - Cathy O'shana Owner Owner's Name information is O required for every SteNille MA 02655 9-18-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): Leaching is two 1000 Gal Precast'Pits Both pits are 6' below grade w/covers at 33", Both pits are wet, no sign of overloading, solid cagy over or high stain line, wall clean 2'stone per asbuilt 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 15ins•11110 Tulsa 5 Official Inspection form:Subsurface Sewage Disposal Sotarn-Pape i3 o117 Sep 18 12 10:38p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Robbins St Property Address Cathy O'shana Owner Owner's Name information is required for every OsteMlle MA 02655 9-18-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic.failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions. Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): is ns•wt o Tills 5 Offle6l[ropeclion Fornx SLbsuriate Sewage plspo6al System•Page t4 of 17 Sep 18 12 10:38p p.15 Comrnonwealth of Massachusetts- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Robbins St. Property Address Cathy O'shana Owner Owner's Name inform at required for every ion is Osterville MA 02655 9-18-12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A -1 _ �LS , 13- 31= 7" t51ns• too Title 5 Official Inspeetion Forth:Subsurface Sewage Disposal System•Page 15 of 17 Sep 1812 10:38p p.16 , o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 108 Robbins St. Property Address Cathy O'shana Owner Owner's Name information is required for every Osterville MA 02655 9-18-12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 16+' 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 ithin 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_ Hand auger 4' below bottom of pit, Bottom of pit at 12" auger hole 16', No G.W. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t6krs•I U10 Title 5 Officief inspection Fors:Subsurface Sewage Disposal System.Page 16 of 17 Sep 18 12 10:39p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 108 Robbins St. Property Address Cathy O'shana Owner Owners Name information is required for every Osterville MA 02655 9-18-12 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Wins-11110 Tide 5 Widal Inspealon Form:Subsurface Sewage Disposal Systarn-Pago 17 of 17 APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS !� �OCATIQN 1 �` ;3 S 5 LET N0. �`U 7' l VILLA pE T. c%�� DATE '' . FEE 1DDRE Sig TELEPHONE NO. (Non-refundable, :.NGINEE T �. r' C.�-.��I--yc Ig _j N.��c-,i/= TELEPHONE GATE SCHEDULED - /(a 'I S:" /G rid' :_,•;. ;• (Applicant' s signature � . % . . . . . .. . . . . . . . . . .. . . . . . . . . . .e o . . . . .OTN0 /ASSESOSAPG L SOIL LOG SUB—DIVISION NAME LG" / 7.3 L DATE TIME 11 4,11 . EXPANSION, AREA: YES INO / /�.��:J/� ENGINEER . rOWN`,yATER ✓PRIVATE .WELL BOARD OF HEAL•TF �¢P�<� G:,.�;i• EXCAVATOR SKETCH:, (Street name„etc. ,dimensions of lot-, exact location of test holes and percolation tests, locate wetlands in proximity to est holes) NOTES: w`�, • I goo� .. T. r r ,reg7 AIVr r I. .• 2 w, 1 / ?ERCOLA'l' ZT .RATE C- -S tAN ,r LEST JOL , :.No: ELEVATION: TEST HOLE NO: ' ELEVATION: ;�j 3"is� � � �S 1 T_�s• 1 of 2 3 3 r u 4 6 . , 7 A A) 7 F�, g 8 ' 9 9 o to 12 12 13 A"d 11zv 13 14 . 14 15 ' 16 16 ;UITAB E F•OR SUB-SURFACE ,SEWAGE: LEACHING FIELD LEACHING PITS LEACHING TRENCHES JNSUITABI+E FOR SUB-SURFACE SEWAGE. REASONS: ]OTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION )RIGINAL: COMPLETED IN ENT RET P AN ETURNED TO BOARD OF HEALTH ,:OPY: " RETAINED BY APPLICANT $OIL LOS \XLl�1.AlI�Y�\Vuv-,J/nter�/5.i.�i�wy/ -L-JL/x 58-03 2".PEAS TONE � LOAM 6 FILL 12"MAX, �e 3 777 °• a � s„gso.IL aj`.-o 3 &I j 4 C.I. DIST. Cr„a.cs BOX 5'MIN. 100000°° 1000— GAL. o GAL I °° PRECAST OR ° C/ m 3 SEPTIC 6'�ooe BLOCK °p TANK �'• ° SEEPAGE PIT ' I , o ° erg SoN) 89. .53 D ° P 1° • ° O 0 I �..fJ��•j o p t o v O D G7�q�l L &$.6-3 e p q 20, MINIMUMo,° • L �� cL�'++ (�{ FOUNDATION I I S-so, A $6. 0.3 `g I %z' WASHED STONE SCALE: ELEVATION SKETCH r` 1IZ PaRc. RAT¢ Not 2- •-,�wG.� SCALE; I"= 4' TEST BY . e.=�.�a4f•.�a�/4•w• r3�'cL TOWN INSPECTOR: + -Z' S BACKHOE OPERATOR �.,a�.v� * TEST MADE ON ; S. s 430?.7 9 0 \ qq qa A� q�x q'1► %000 GP.— LrcAG4��w��o 4 Ex P��►a►a. I 0 � C>l5�\ 98 � �. eax . N\ l i IN t N 20'0 lip 1 P,Qo post_ 1` Ali 01 1 01 p 0Iric.cC 0 Q\ I� t COO q� n "�- - - - so• i \ � 3 or LET � 97o a Q qy .14 APPROVED BY BOARD OF HEALTH DATE 19_ 00 �" d �..� 10 T i H OF MA3s9 -� i c -- RENWIC B. 9N 1 r] c� CHAPMAN C4 o p N . 27654 O �o �IST 9b co ELE�'A.T�ana �rsS/OVAL ELEVATION SCHEDULE PROPOSED .SITE PLAN I. INV. AT FOUNDATION = �(o•Sv • q � � SEVABE . SYGM3 DIESIGH 2. INV. INTO SEPTIC TANK = O IN 3. 1 NV. OUT OF SEPTIC TANK = � /� yri�✓N,s , Fore g 5 4. INV. INTO. DISTRIBUTION BOX q(o.05 SCALE I -�o' r�r.•aRc� 19"�7 5. 1 NV OUT OF DISTRIBUTION BOX is' C—SSA 6. INV INTO SEEPAGE PIT c IS.7S CAPE CE➢CS SURVEY CONSULTANTS q ROUTE 132 7BOTTOM OF PIT = 0,° 7 HYANNIS, MASS. A DIVISION BOSTON SURVEY CONSULTANTS, INC. B. BOTTOM OF STONE LAYER = _90