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HomeMy WebLinkAbout0129 ROBBINS STREET - Health 129 ROBBINS ST., 0STERVILLE - 1# No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pphratton for Oigpooal *patent Couotructton j3ermtt Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( )- Complete System ❑Individual Components Location Address or Lot No. v 4,1 G Owner's Name,Address Ns- 1 0andTel.No. �r Assessor's Map/Parcel V, �� A P c Te``� CQ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. wti--CA V��C a0 wn;c Ik Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. . Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 753 0 gallons per day. Calculated daily flow �4cj gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank l�W 14 '/���✓ Type of S.A.S. Pvcv Ck 611 t Description of Soil Nature of Repairs or Alterations(Ans er when applicable) :3— TW y\ N5 U� -S dGrtH�I� 3 �� �(L 1 ui iLT�az-o 25 u 1 5rt otti S►bfj_ 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 vironmental Cod and-not to place the system in operation until a Certifi- cate of Compliance has bee y t us o Signe 4 Date l-)Me Application Approved by Date Application Disapproved or the following reaso Permit No. Date Issued 1 �V N . �../ "'" Fee f" o THE,,COMMONWEALTH-OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS J !r 0(ppYication for Mi_4possal *p.5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) )5Complete System O Individual Components Location Address or Lot No. a uW� 5 G Owner's Name,Address and Tel.No. r Assessor's Map/Parcel SeACI ` CQ i DEG �. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. `�-Se Q`� C- Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria(. ) Other Fixtures Design Flow 33 y gallons per day. Calculated daily flow �C( gallons. Plan Date x, Number of sheets Revision Date Title _ Size of Septic Tank 17S CU A ''nn Type of S.A.S. � C� 7 Description of Soil 5 VJ Nature of Re airs or Alterations(Ans er when applicable) V4= T;W �0 2c. cN 2- C_ci u i L r�To 2`S u�, 4 Srt ry e_ o w i h e, n Date last inspected: Agreement: r 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 4pvironmental Cod and not to place the system in operation until a Certifi- cate of Compliance has bee 5' y Rthiso flea:'Signe` Date Application%Appl- d'by Date Application Disapproved for the following reaso Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS + BARNSTABLE, MASSACHUSETTS s Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded Abandoned( C-- at b constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Aated Installer Designer The issuance of this pe t shall not beCc�ons ued as a guarantee that the syste ill function as designed. Date /f' s Inspector 2, No. _......-� -------------------------Fee-�y4,�— THE COMMONWEALTH OF MASSACHUSETTS v PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mi5potar *pgtem Con5truc-ion Permit Permission is hereby granted to Cons ct( ) (_ )Upgrade( )Abandon(( ) System located at ft�Ji�5 ST and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction Est be cd fed within three years of the date of tl iermit. 0 Q Date: Approved by T jx ' 10/9197 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only: 1 CERTIFICATION OF SKETCH AND APPLICATION FOR A ® DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed by me dated �`��—� , concerning the rt located atFivt,� meets all of the property following criteria: There are no wetlands located within 100 feet of the proposed leaching facility There are no private wells within 150 feet of the proposed septic system , m There is no increase in now and/or change in use proposed There are no variances requested or needed. 0 X If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility,will ambe located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. Please complete the following: _ •_-- ineerin Division G.I.S.map) � �L A)Top of Ground Elevation(according to the Eng g ivision well map) 5 ` B)Observed Groundwater Table Elevation(according to Health D _ 34.t SIGNED: DATE: l a LICENSED SEPTI SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. I q:health Iblder:can i 4 �, �� f ^\l`^` Cv V' C. t'i • TOWN OF BARNSTABLE LOCATION q AaAb) Als A - . SEWAGE # 10 - VILLAGE• 6 1- L d?U/Ike, ASSESSOR'S MAP & LOT / INSTALLER'S NAME&PHONE NO. mi b a a .Sew 4 l C SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 1 -' ��CaCOMPLIANCE DATE: /l -'1 Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 t '�_ � W �. � R.. 0 A. fr_. ��,, TaaWROF BARNSTABLE LOCp►TION. o� / �o ��r 5 - _SEWAGIE # �/ILLA CaC ASSES MAP$i LOTS,_ WSTALLER' t`tAI 8t k'FiC3NE Y O I SEIyIdC TAN X.CA1r'AC3TY " LEACFt�NG ACMI ff, (type) n J I`t0.0k� > Rk2047NdS �.. :i PE ITbA'E: --COW, CE DA :.._..,._....�..� ( Sepr ae►aet i $'tv� n cue Maximum Ai1)as t!Gtpund vrattrt Ttzt?le to ills attom of Leaching R ility -. 1'clv�teW6t Supply L ilcal iWdtc. a fig aellity (6r iy vielis exist �cea ' cis s�tc�,ae wit��n hing f�cility) .- --- ---a---�•--- F,ci�;ts cyflet9n�c9 ai�t Leaching i~�cixlty(if sany wetlands exist Lee 1+itlaica:10Q feet at ieaa an$tucitsty} (,t Qi, i n MCA V-,NA q � O rZA i i n . w 1 a } 77�Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface,Sewage Disposal System Form -Not for Voluntary Assessments 129 Robbins St Property Address Robert Olds Owner Owner's Name information is Osterville MA 02655 9-24-13' 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. A. General Information 1. Inspector:' ` a p 5 Shawn Mcelroy' Name of Inspector *' Upper Cape Septic Services �. Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify than have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ' ® Passes ❑ ,Conditionally Passes,, ❑ Fails A. ❑ Needs Further Evaluatio by the Local Approving Authority 9-24-13` ' Inspector's 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. t5ins•3113 Title 5 Official Inspection F ubsurface Sewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts Title 5 OfficialInspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Robbins St Property Address Robert Olds Owner Owner's Name information is required for every Osterville MA 02655 9-24-13 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: System is in good working order with no sign of failure. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Robbins St t Property Address Robert Olds Owner Owner's Name u- • u information is MA 02655 9-24-13 required for every OSteNllle • . page. City/Town _ State Zip Code 7 Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms`are repaired. r. 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): 3 ❑ broken pipe(s) are replaced ❑"Y` ❑ N, ❑ ND (Explain below): ❑ obstruction is removed _t ❑i Y ❑ N ❑f 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 orderto determine if. the system is failing to protect public health, safety or the environment. I.".System will pass uniess 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 t5ins-3/13 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 f r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Robbins St Property Address Robert Olds Owner Owner's Name information is required for every Osterville MA 02655 9-24-13 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) r ' F 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. I ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed,at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence,of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due,to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the.ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool,is less than 6" below invert or available volume is less than %day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 C _ Commonwealth of Massachusetts Title 5 Official Inspection Form: Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. ; 129 Robbins St Property Address Robert Olds t, Owner Owner's Name information is required for every Osterville .: ':i ,<,, MA 02655. 9-24-13; page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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. El Z . 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 colifonn bacteria indicates absent and the presence X.. 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.] 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 Il,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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 , Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Robbins St Property Address Robert Olds Owner Owner's Name information is required for every Osterville MA 02655 9-24-13 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the followinghave been done. You must indicate es or"no as to each of the following: Y 9 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? I ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example:110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. .. . . °M 129 Robbins St , Property Address Robert Olds .T Owner Owner's Name information is �.- required for every Osterville- z . , -. MA 02655 9-24-13, a e. City/Town State Zip Code bate of Inspection P P 9 D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry-on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No . Seasonal use? ® Yes ❑ No Water meter readings, if available (last,2 years usage (gpd)): Detail: Sump pump? ' w ❑ Yes 0 No .i Last date of occupancy: 8-2013 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on.310 CMR 15.203): Gallons per day(god) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present?, z , _ _ ❑ Yes ❑ No Industrial waste holding 4ank.present?,x ❑ ,Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 129 Robbins St Property Address Robert Olds Owner Owner's Name information is required for every Osterville MA 02655 9-24-13 page. City/Town 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: N/A 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 129 Robbins St , Property Address Robert Olds Owner Owner's Name - information is required for every Osterv.ille; 4 MA 02655 9-24=13 a page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date.installed (if known) and,source of.information: 1998 Were sewage odors detected when arriving at the site? : ❑ Yes ® No Building Sewer(locate on site plan): , ' Depth below grade: 36"feet Material of construction: { ❑cast iron ® 40 PVC T' i"El other(explain): ` . . k Distance from private water'supply well or suction line: feet Comments (on condition of joints, venting; evidence of leakage, etc.): Good condition. Septic Tank (locate on site plan)' Depth below grade: .. 30"• 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)' 'w' ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5' Official Inspection- Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Robbins St Property Address Robert Olds Owner Owner's Name information is required for every Osterville MA 02655 9-24-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Y ,..Distance from top of sludge to bottom of outlet tee or baffle 2011 1 11 Scum thickness Distance from top of scum to top of outlet tee or baffle 611 i Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape 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 in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: ` feet Material of construction: q ❑ concrete ❑ metal ❑ fiberglass- ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness r 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Robbins St Property Address r Robert Olds ;s Owner Owner's Name information is r required for every Osterville:--. ,, MA 02655 9 24=13TP- page. 'City/Town:: : ::. State ,Zip Code Date of Inspection D . System Information (cont.) :: =1,t Comments (on pumping recommendations, inlet and outlet tee or.baffle condition, structural integrity, R liquid levels.as related to outlet invert, evidence of leakage,"etc.): t Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): m Depth below grade: Material of co nstr"uction: concrete ❑ metal '❑ fiberglass. ❑ polyethylene- ❑ other(explain):" Dimensions: Capacity: e . gallons Design Flow: i f � d.y '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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 129 Robbins St Property Address Robert Olds Owner Owner's Name information is required for every Osterville MA 02655 9-24-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Good condition with water at working level and no sign of back-up from field. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms'in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: , t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 129 Robbins St Property Address Robert Olds Owner Owner's Name - information is required for every Osterville _. MA 02655 9-24-13 page. City/Town State Zip Code 'Date of Inspection D. System Information (cont.) x, Type: 0 ❑ leaching pits number: ® leaching chambers number: 4-Infiltrators ❑ 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.): Infiltrator leach field in good condition and empty at inspection with no sign of back-up into d-box or surrounding stone. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM ; 129 Robbins St Property Address Robert Olds Owner Owner's Name information is required for every Osterville MA 02655 9-24-13' page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) t 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.): t5ins=3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Robbins St Property Address z Robert Olds . :t ; 0 Owner Owner's Name , information is Osterville MA 02655 9-24-.13r, r M required for every page. City/Town 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 V ❑ drawing attached separately k. c _ u 14 =F +r r t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 129 Robbins St Property Address Robert Olds Owner Owner's Name information is required for every Osterville MA 02655 9-24-13 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: 12 .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: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 12'. Before filing this Inspection Report, please see Report.Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 129 Robbins St Property Address Robert Olds Owner Owner's Name information is - Osterville MA 02655 9-24-13 required for every � � - page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION I�`1 R 0A b l VS 6 J ° SEWAGE # VILLAGE L CTG R1/1 I e ASSESSOR'S MAP & LOT f o tj INSTALLER'S NAME&PHONE NO. /►'l10 ape. Sea 4 1 G SEPTIC TANK CAPACITY �S o ^o j LEACHING FACILITY: (type) ZNt I1 T PN 16 S (size) L I _ NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: &-1_;'^i6 COMPLIANCE DATE: Il Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 1 Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by A o 13 i I i I . +aa zo•-0• ze•a � I A A i , i I I zaa L1 za +sue 3!a• B•s va• zr-+o• Y I EXPANDED r<' s-1+TS• 3a sa+s DECK e —————————- A3 v A B AT' MAWN AINM1'TEGIRTTY A3IINTEG TTY INTEGRITY INTEGRITY CLOS. ID.3 WYtlN= WN3=DH3Z58_ NEW© wNc. BATH EXIS UPON 1\4 UPKITC $ 1 �. A• I b RAILING § _ 0 NEW;i r. rFA�VIiLY P 4 MARVIN CLOS. ----- ROOM I { O (VAULTED CEILING) 1 -. NEW 3,-0• B•-0- NEW_— IDH32W _-_ - NEW mAC-— GARAGE EXIST. b MARVIN o- ® EXIST" __ I T . § BEDROOM © m3z NTEGW Y r � � © Hsz BATH LIN. Io , 2S'X TE DiDOOO RA ..' a n fff����� J yb( = -- � r----------� r— -- — ————_____ ___ LINE OF WALL BELOW I I INSTALL ACCESS v�CLO$ MARVIN 'NTE IG ® ° n I I PANELS I I a NEW i iG DH3� b COVERED PORCH I ° EXIST. CLOS. mm'2rl § BEDROOM A � A3 A MARVIN MARVIN A3 IN GIN MNi INTEGRITY INTEGRITY INTEG.RI IDH3258 B IDN3256 IDF13298 IDH32a8 A B z>. r-0• z-0• re• 2•R" r-t0• 5A' a•<• Ta 16'a ra a'$ 4•8• 9'-0• a'$ 4'-8• -- zaa zaa zaa NOTES: f FIRST FLOOR PLAN 1.)CONTRACTOR IS TO VERIFY ALL EXISTING CONDITIONS SECOND FLOOR PLAN &DIMENSIONS IN THE FIELD 2.)CONTRACTOR TO VERIFY ALL INTERIOR L EXTERIOR MATERIALS, LEGEND: DETAILS,&FINISHES IN THE FIELD WITH OWNER 3.) ROUGH OPENING HEAD HEIGHT OF WINDOWS AT O EXISTING WALLS FIRST FLOOR TO BE 6'8"ABOVE SUBFLOOR 7 CONSTRUCTION TO BE REMOVED 4.) ALL CONSTRUCTION TO CONFORM TO 780 CMR MASSACHUSETTS NEW CONSTRUCTION STATE BUILDING CODE,8TH EDITION AMENDEMENT&IRC2009 IECC2012 RESIDENTIAL ENERGY EFFICIENCY DETAILS EM 5.) ALL WINDOWS&DOORS TO HAVE SILL PANS&ICE/WATER SHIELD FLASHING 6.) 110 MPH EXPOSURE B WIND ZONE,1.50 ASPECT RATIO CLIMATE ZONE 5A(USE EITHER PRESCRIPTIVE VALUES OR RESCHECK CALCULATION ©SMOKE DETECTOR 7.) ALL SHEETS OF PLYWOOD WALL SHEATHING TO BE INSTALLED VERTICALLY, TABLE 402.1.1(MINIMUM PRESCRIPTIVE INSULATION&FENESTRATION REQUIREMENTS) OR HORIZONTALLY W/BLOCKING AT EDGES,3"EDGE/12"FIELD NAILING FENESTRATION SKYLIGHT CEIANr. wooD FRAMED wAu FLOOR BASEMENT—BASEMENT SLAG CRAWLSPACE WALL CARBON MONOXIDE DETECTOR U-FACTOR WFACTOR 1.7 -VALUE R•VN.UE R-VALVE R-VALUE R-VANE R•VALUE © 8.) ALL LVL LUMBER/BEAMS TO BE 1.9e L/480�LOAD oas o.Bo as zo 30 +a+3 10(2FT.DEEP) JIM13 ®HEAT DETECTOR 9.) SEE CERTIFIED PLOT PLAN DEVELOPED BY CAPESURV FOR ALL PROPOSED&EXISTING DETAILS NOTES: 1.R-VALUES ARE MINIMUMS 8 U-FACTORS ARE MAXIMUMS. 10.)FOLLOW ALL MANUFACTURER'S SPECIFICATIONS FOR INSTALLATION OF ALL 2.10113 MEANS R=15 CONTINUOUS INSULATED SHEATHING ON THE INTERIOR OR EXTERIOR SIMPSON COMPONENTS. OF THE HOME OR R-13 CAVITY INSULATION AT THE INTERIOR OF THE BASEMENT WALL 11.)ALL CONCRETE USED FOR FOUNDATION WALLS,FOOTINGS&SLABS 3.REFER TO IECC 2012 CHAPTER 4 FOR ALL INSULATION&ENERGY REQUIREMENTS TO BE 3000 PSI . 12.)VERIFY ALL PLUMBING&ELECTRICAL DETAILS W/OWNERS ON THE SITE 18.)MARVIN INTEGRITY WINDOWS&DOORS,WHITE EXTERIOR DURING FRAMING CONSTRUCTION SIMULATED DIVIDED LITES,IMPACT GLAZING 13.)THIS SITE IS IN THE 110 MPH WIND BORNE DEBRIS AREA,EXPOSURE"B" 19.)VERIFY LOCATIONS FOR ALL ELECTRICAL,GAS,&WATER - &WITHIN ONE MILE OF NANTUCKET SOUND PER STATE OF SERVICE INTO THE HOUSE&NEW ADDITION MASSACHUSETTS WIND SPEED MAPS 20.)GAS FIRED FORCED HOT AIR HEAT&AC SYSTEM WITH 14.)GLAZING PROTECTION PER 780 CMR 5301.2.1"2 TO BE IMPACT GLAZING ON DEMAND WATER HEATER FOR NEW ADDITION VERIFY ALL WIND BORNE DEBRIS PROTECTIONREOUIREMENTS W/OWNERS PRIOR TO START OF CONSTRUCTION 15.)TIMBER FRAMING TO BE SPRUCE/PINE/FIR NO.2 GRADE 16.)ALL EXPOSED SIMPSON PRODUCTS&FA§TENERS TO BE MADE OF STAINLESS STEEL 17.)ALL AZEK TRIM TO BE PAINTED WHITE&¢LL JOINTS/NAIL HOLES SEALED. THE DESIGNER SHALL BE NOTIFIED IF ANY COTUITBAYDESIGN. LLC NEW ADDITION/REMODELING FOR• a CONORSCTION. HEBUIDINGCO OR OMISSIONS ARE DON SCALE : DRAWING NO.: THESE DRAWINGS PRIOR TO START OF 43 BREWSTER ROAD MLL BE CONSTRUCTION. FOR HE CONTENT WILL BE RESPONSIBLE FOR THE CONTENT 1/411� 1 I-o11 ` THESE DRAVVINGS IF CONSTRUCTION MASFIPEE,MA. 02649 DDEESIGGNERnCES ROOFA"YEERRORNRSOR MISSIONS. PH.(�08)�274 1166 OLDS RESIDENCE THESE DRAW N°8 ARE.MY O HER THE USE DATE FAX 50S 539-9402 THEM THE OWNER NOTED.ANY OTHER USE OF 129 ROBBINS ROAD OSTERVILLE, MA AT,�DCWALCOPYIIGHTPROTECTION 10/3/2014 CONSENT OF THE DESIGNER UNDER THE CT OF ARCHITECTURAL COPYRIGHT PROTECTION +(�