HomeMy WebLinkAbout0075 SCUDDER ROAD - Health 75 Scudder"Road
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS �J
APARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
IFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
�eroperty Address: 75 Scudder Road
Owner's Name:
Osterville MA 0265.5
Don Lukens
Owner's Address:
Date of Inspection: August 30 2007
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Osterville MA 026SS-0049 '
Telephone Number: (508)862-9400
CERTIFICATION STATEMENT. `
I certify that I have personally inspected the sewage dis
below is true,accurate and com posal system at this address and that the information re
of time of the:inspection. The inspection was performed based on por
plete as f th tbd
poke
training and experience in the proper function and maintenance of on site sewage disposal systems. I a a DEP.T1
)• The system
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000 y
- : ;, _
✓ Passes �'
Conditionally Passes c
Needs urther Evaluation by the Local Approving Authority'
Fails.
s�
Inspector's Signature: i�
Date: Se tember 4 2007
The system inspector shall sub mi copy of this in pection report to the Approving Authority(Board of Health DEP)within 30 days of completing this inspection. If the system is'a shared system or has a design flow of 10,000
lth or
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 approvin
authority.
g
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 Inspection Form 6/15/2000
page I
® Page 2 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 75.Scudder Road
Osterville, MA
Owner: Don Lunkens
Date of Inspection: August 30 2007
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 com mores stem components.as described in the"Conditional Pass"section need to be replaced or
Y P
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. „
Answer yes,no or not detenmined(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
i
Page 3 of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A -
CERTIFICATION (continued)
Property Address: 75 Scudder Road `
Osterville. MA
Owner: Don Lunkens
Date of Inspection: Aurrust 30 2007
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 Lof 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.
j 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 aimnonia 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
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 75 Scudder Road
.Osterville. MA
Owner: Don Lunkens
Date of Inspection: August 30, 2007
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
✓ 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 tunes 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 I 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 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.
Page 5 of 11
OFFICIAL INSPECTION FORM-,,NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B _
CHECKLIST
Property Address: 75 Scudder Road
Osterville, MA
Owner: Don Lunkens
Date of Inspection: August 30, 2007
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 backup?
✓ Was the site inspected for signs of break out?
I
✓ _ 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.
✓ _ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 75 Scudder Road
Osterville, MA
Owner: Don Lunkens
Date of Inspection: August 30 2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: n/a
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage 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: Currently occupied-
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc:):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitay 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): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach-previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
new leach field added on 2110103-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 75 Scudder Road
Osterville. MA
Owner: Don Lunkens
Date of Inspection: August 30, 2007
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: 20"
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 awl_.
Sludge depth: 2'r
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum.thickness: 4"
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
Comments(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.
GREASE TRAP: None (locate on site plan)
Depth below grade: '
Material of construction: _concrete _metal _fberglasss _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.):
B
Page 8 of 11
OFFICIAL INSPECTION FORM-,NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 75 Scudder Road
Osterville, MA
Owner: Don Lunkens
Date of Inspection: August 30, 2007
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 alann and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even.
Conunents(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.):
The D-box was level. No solids were present. The older system, The infiltrators were taking most of the flow.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no): -
Alanns in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.(continued)
Property Address: 75 Scudder Road
Osterville, MA
Owner: Don Lunkens
Date of Inspection: August 30, 2007
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why: K
Type
leaching pits,number:
leaching chambers,number: Inditrators.
✓ leaching galleries,number: 3-Drywells
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.):
The Drywell were dry and clean. There did not appear to be any signs of failure. The infiltrators were taking the flow but were
full. A camera was used to inspect both leach fields.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding;condition of vegetation,etc.):
PRIVY: None (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.):.
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 75 Scudder Road
Osterville, MA
Owner: Don Lunkens
Date of Inspection: August 30, 2007
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters.the building.
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�, y 3-1 37
10 Sa-
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.0
q
SYSTEM INFORMATION(continued)
Property Address: 75 Scudder Road
Osterville, AM
Owner: Don Lunkens
Date of Inspection: August 30, 2007
d
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25+/- 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 groundwater elevation:
Using Barnstable topographic and water contours maps. the maps were showing approximately 25'+/ 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
function properly in the future. 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.
I1
• 'a
Town of Barnstable
Op 114E I',
Regulatory Services
S,,,B Thomas F. Geiler,Director
r$ 1 `0g
A,Eo �A Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be-listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
TOWN OF B STABLE
Q
LOCATION Sctj (PGA R SEWAGE#
iLLAGE osllrV ASSESSOR'S MAP&PARCEL I90- 0l P
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY / !;'#D
LEACHING FACILITY:(type) P ► Size)
NO.OF BEDROOMS G/
OWNER / y ►1 G/1J
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 BY 1-4 PT7M
�' ► Mo a9
ci o a ao
M y 3-) 3 )
� 30 S�-
- ' TOWN OF BARNSTABLE
LCr�:-4TICN ~Z Sc�vY�� 44 SEWAGE # ?'003. 042
VrLLAGE ASSESSOR'S MAP & LOT I�L-Q 0
INSTALLER'S NAME&PHONE NO. ((:;.LI L tLX-1t ole,
SEPTIC TANK CAPACITY 60®
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS 3
BUILDER OR OWNER
PERMPTDATE: Z q10 ' COMPLIANCE DATE: ,Z 0 0 4
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 f leaching facility) Feet
Furnished by 7'�
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-�� 17�7 L7
No. v � � Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zippfication for Mitpoeal *p5tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot N . Owner's Name,Address and Tel.No.
Assessor's Map/Parcel CJS
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
F_ A,0
Type of Building: l L
Dwelling No.of Bedrooms q Lot Size o ""�sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow It 6 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil S t.96,4 Lo&,GLA_ '
VA_�
Nature of Repairs or Alterations(Answer when applicable) t bc��e t 18F dc�/�Vti
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this Board of ealth. /
Signed Date C /0
Application Approved by Date
Application Disapproved for the following reasonlirl
Permit No. n Date Issued
No. ' .. (�• Fee
" `E ti R k ,. <' Entered in computer:
THE COMMONWEALTH OF MASSACHUSETTS-.�----�-� yes
PUBLIC.HEALTH DIVISION - TOWN OF BARNSTABLE,, MASSACHUSETTS
trJ�
ricatiott for Mtgaat *pttem� 0ongtructt".on Permit
,
Application for Peinut'to Construct( . )Repair( )Upgrade(�)Abandon( )A,Complete't System em ❑Individual Components
Location Address or Lot N . Owner's Name,Address a d!Tel.No. •/
Assessor's Map/Parcel
�� 1✓w
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building: x v
Dwelling c, f No,.of Bedrooms Lot Size r'"v sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures ' l• a
Design Flow -4 L16 + gallonss per day./Calculated daily flow gallons.
Plan Date A-Number of sheets a Revision Date
Title
Size of Septic Tank i i j I Type-,of S.A.S
Description of Soil 14_►^���-c
Nature of Repairs or Alterations(Answer when applicable) A W t k->!N k0c,sv%- `
r
Date last inspected: `
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b this Board of ealth. /
Signed Date 1/ .s/o
Application Approved by
Application Disapproved for the following reason
,
J 1
Permit No. / ...� Date Issued--- -'X 44
------------------- ---------------- -- ,
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
art Certificate of Compliance 4.
+ THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(---),Repaired( Upgraded( )
A Abandoned( )by
at '7 sc,ww T � `��� �� has been construct d in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No ad I Z (I0 3
r
Installer Designer
The issuance of t`is pdrmit shall not be construed as a guarantee that the system wit c,is`,;fi/fis-de.'gne
Date 2-/!o 110 3 Inspector lw
----------------------------------------
No. f�/ Fee -
THE COMMONWEALTH OF MASSACHUSETTS s.
PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS
Mizpool 6potem Conotructton Permit
Permission is hereby granted to Construct Repair( ) pgrade Q Aba on( )�
System located at i f
v
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:Constn4ctj6h st be completed within three years of the date of this'e ter
Date:_ �l Approved by < <�
i TOWN OF BARNSTABLE
LOCATION 5 SEWAGE #
ASSESSOR'S MAP & LOT J q0`0�1
� VILLAGE,
_ -fie"
INSTALLER'S NAME&PHONE NO. to
SEPTIC TANK CAPACITY
i LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE:
Z={ 6 COMPLIANCE DATE: Z D .
4
Separation Distance Between the: Feet
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility)
exist
Edge of Wetland and Leaching Facility(If any Feet
within 300 feet of leachincility)
Furnished by
I
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DATE: 4/1.4.1.99
PROPERTY ADDRESS: •75 Scudder road
OsterVille ,Mass .
b2655
t
On the above date, I Inspected thes•eptic eystom at the above addre8e.
Thld system Conalsts of the following:
1 . 1-1500 gallon septic tank. '
2 . 1-Distribution box .
3. Cultec rechargers .
Based bn my Inez-action, I certify the following conditions:
4 . This . is a title five septic system. to '
5. The sept-ic' sys`tem' is °in properortcng t(grder = :
a£ the present time £ . .....mr _ i". •�;, h. ` .
_ ., •.
81GNATUFt13Y �
• 1 d
Namo : J . P. KeComber i
Company•_J. P ,Hacotgber• b � on- 'Inc ,, '♦' °�
-•---------
•Address: A P R 2. 3 1999 co866_;.,.__.'.1_..
`7
T=0F
__den cp•}v� 1 Le �K.433.i_Q?b3.2• •' '� . �
Phone:__;,54&�:2�..5-J33.8___'____ I
8
THIS CERTIFICATION DOES NOT. CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER '& SON; INC,
T+nkkC@upooIkLsachflaldi
Pvmp+.d 6 Iniuli '
td
• Town, S♦wor Connoctlons
P.O. Box 66' Cwcrvlllc, MA 02632.0066
77.5.333-8 77S-6412
t
COMMONWEALTH OF MASSSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property address: 7 5 Scudder Road Name of o,,,.L o u i s Emrich
Osterville ,Mass. Addressofownw: 40 Swift Ava
Date of inspection: 4/14/9c� Osterville ,Mass . 02655
Name of Inspector:(Please Print) J O S e A h P.Macomber J r.
I am a DEP approved system Inspector pursuant to Section 15.340 of Title 5(310 CMR I S.000)
company Name: .J.P.Macomber & Son T n c -
M-TaV Address: -Box 6.6—Cant-e-r wi-3-1-e-,Mass . 2 6 3 2
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The Inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes`
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails o !�
51
Inspector's Signature: ' Date: 4 // `✓
The System Inspec or hall submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)whhin thirty (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 Department ofrEnvironmental Protection. The original should'be.sent to"
system owner•and copies sent to the buyer, if applicable, and the approving authority. .
NOTES AND COMMENTS
revised 9/2/98 Page Iofll
`J Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART A
CERTIFICATION (continued)
PropercyAddress: 75 Scudder Road Osterville ,Mass .
Owner: Louis Emrich
Date of Inspection: 4/14/9 9
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are Indicated below.-
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
�d 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.
Indicate yes,ano, or not determined (Y, N,or ND). Describe basis of determination in all Instances. If "not determined", explain why not.
Ali The septic tank Is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was Installed within twenty(20) years prior to the date of the inspection; or
the septic tank, whether or not metal,Is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
A/D Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
- The system required pumping-more tharcfourtimes a yeardue to broken or obstructed pipe(s). The system wNtjmss--
inspection if(with approval of the Board of Health): - -
broken pipe(s)are replaced '
obstruction is removed
revised 9/2/98 Page 2of11
/1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART A
CERTIFICATION (con*x►ed)
PropertyAdtireea: 75 Scudder Road Osterville ,Mass .,
Owner. Louis Emrich
I of Lnspectlon: 4/1 4/9 9
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 falling to protect tt
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 C)dR 15.303 (1)(b)THAT THE S1
IS NOT FUNCTIONING W A MANNER WH1CAYALLPROIECT THE PUBLIC HEALTRAND SAFETY AND THE DAa80NU0fT-
T� Cesspool or privy is wlthIn 60 fest of surface water
bts� Cesspool or privy Is within 60 feet of a bordering vegetated wet)and or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETEPJALUES THAT THE SYST
FUNCTIONING IN A 4UINNER THAT PROTECTS THE PUBUC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and toll absorption system(SAS)and the SAS Is within 100 test of a surface water supp
tributary to a surface water supply.
/►fib The system has a &optic tank and soil absorption system and the SAS Is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS Is within 60 foot of a private water supply wou.
The system has a septic tank and soil absorption system and the SAS Is less than 100 foot but 60 foot or mote from a
private water supply wall,unless a wall water analysis for coliform bacteria and volatile organic compounds Indicatos V
wall Is free from pollution from that facility and the presence of-ammonia nitrogen and nluate nitrogen Is ►qual to or Io
than 6 ppm. Method used to determine distance (approximation not valid).•
3) OTHER
A
s
� I
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "
PART A
CERTIFICATION (continued) '
Pr address: 75 Scudder Road [0sterv'i,li'e Mass:..
oa�Y � ,
Own": Louis Enrich
Date of Inspection: 4/14/9 9
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following,: i
AM I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. 'The Board of Health should be contacted to'determina'what will be necessary,to correct the failure.
Yes No /
Backup of•sewage into leciii"r-astern componentduego an overloaded orgylegged-SAS-or1Ce33p001. y- '
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 distnbu o�n�bbo above outlet invert due to an overloaded or clogged SAS or cesspool. ,
.;
_ Liquid depth in c'&"p*eLis less than 6''below'Invert or available volume is less than 112 day flow. °
Required pumping more than4 times in the last year NOT due to clogged or'obstructed pipe(s).
Number of times pumped X '
Any portion of the Soil Absorption System, cesspool or privy is below-the high groundwater elevation. -
Y >
Any portion of a cesspool or privy is within 100 feet of-a surface water supply or tributary to a surface water'supply.
111 Any portion of a cesspool or privy is-within a Zone I 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 than50 feet from a private water supply well with no
acceptable water quality analysis.,If the well has'been analyzed to be acceptable, attach copy of well water analysis for
-•coliform bacteria, volatile organic.compounds;ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
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:
/ The system serves a facility with a design flow of 10,000 gpd or greater,(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes -
the system is within 400 feet of a surface drinking water supply
the system-is-within 200 feetof-644butary-toe surfao"rinkiwg-we ter-supply ----- . --
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA) or a mapped'Zone 11 of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2)., Please consult the local regional
office of the Department for further infognation.
revised, 9/2/98 Page 4ofIl
j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART B
CHECKLIST
Property Address: 75 Scudder road Osterville ,Mass".
OWE: Louis Emrich:
Date of Inspection: 9 '4/14/9 9
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes • No
Pumping information was provided by the owner,occupant, or Board of Health.
None of the ayatem-compoaants.laa»abean purnpad4os atJeast two%veaks and the rystem hasbaeageceiu+wg+wawul low `
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
Inspection.
_ As built plan,,have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or Industrial waste flow.
V _ The site was inspected for signs of breakout.
_ All system components luding the SoilAbsorption System,,have been located on the site.
The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System orrthe site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
/ (15.302(3)(b))
V _ The facility ownar.land.oc-1paau,if diNeraw from.om=erLwar&pmvidad.withinfnrmatioaDn.tha uDpmraaintanaac"f
SubSurface Disposal Systems.
}
I' revised 9/2/98 Page 5of11
1 -
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r �
PART C
SYSTEM INFORMATION
Property Address: 75 Scudder Road Osterville ,Mass .
owner: Louis Emrich
Dou of 4upection: 4/14/9 9
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 1JO g.p.d./bedro m.
Number of bedroom (Masi n): Number of bedrooms(actual): y
Total DESIGN flow
Number of current resldents:iA&A
Garbage grinder(yes or no):,di
Laundry(separate system) (yes or o : , If yes,separatalnspaction.required
Laundry system Inspected (yes ort
Seasonal use(yes or no):h.19
Water meter'readings,if available (last two year
usage(gpd):
Sump Pump(yes or no):�� 177� �7drS, Ifni•�p LO� L*/,`,Gl
Last date of occupancy:
COMMERCIALANDUSTRIAL-
Type of establishment: A/R
Design flow: ARP Qad l Based on 16.203)
Basis of design flow
Grease trap present:(yes or no)
Industrial Waste Holding Tank present:(yes or no)aQ ry
Non-sanitary waste discharged to the Title 6 system:(yes or no)-9&0
Water meter readings,If available:
Last date of occupancy; V1
OTHER:(Describe) /T
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and ource of Information*
to
System pumped as part of in pection:(yes or no)_
If yes, volume pumped: _(_gallons
Reason for pumping: !L/d
TYPE OF YSTEJM
Septic tank/distribution box/soil absorption system
Single Cesspool
A�d_ Overflow cesspool
A,%6_ Privy
AQ Shared system(yes or no) (if yes, attach previous Inspection records,if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
,10 Tight Tank Copy of DEP Approval
k
Other
APPROXIMATE AGE o ail compoAants,date Ins Ned{if kno y)•end source of4aformation:_
Sewage odors detected when arriving at the site: (yes orno)a -
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART C
SYSTEM INFORMATION(continued)
Prope<tyAd&s-:75 Scudder Road Osterville ;Mass .
Ownet: Lou Emrich
Date of Iru wc.—Uw: 4/14/9 9
BUILDING SEWER:
(Locate on site plan)
l�
Depth below grade:
Material of construction:_cast Iron j240 PVC_other(explain)
Distance from privatewater supply well or auction line 14 1f'
Diameter Q _
Comments: (condition of Joints, venting,evidence of leakage,-etc.)
Joints appear tight - Nn Pvi rjenCe of l enkase
SEPTIC TANK:
(locate on site plan)
rr
Depth below grade: 4
Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank Is (natal, list eye • 1s.age.confumed by Certificate of Compliance (Yes/No)
Dimensions: Al
Sludge depth: _
Distance from top of a to bottom of outlet tee ortaffle: 41
Scum thickness: -
Distance from top of scum to top of outlet tee or baffle: '
Distance from bottom of scum to bonUM of ou a to or bafflere' ,
How dimensions were determined:
Comments:
(recommendation for pumping, condition of Inlet and outlet_tess or-baffles, depth of liquid level In relation to outlet invert, structurs;4ntegrity,
evidence of leakage, etc.) ,Pump - tank every! 2=,�� 'VPAr ; Tn11-t R n1it1Pt- t-pAc
are in n1 ar'P i T _„" ri 1 QUO1 at the ilia 'e�tle>; jI}ve;r't
evi en sound .
Shows ILU
GREASE TRAP:
(locate on site plan)Depth below grade: AhO
Material of construction concrete/�-4metaIdAFibergsass4&PolyethyleneA,6ther(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet too or baffler
Distance from bottom of scym to bottom of outlet too or baffle:A*
Date of last pumping: APY
Comments:
(recommendation for pumping, condition of Inlet and outlet toes or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
Grease trap is not present
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 75 Scudder Road Osterville ;Mass . -
Owner: Louis Emrich'
Date of Inspection:4/14/9 9
TIGHT OR HOLDING TANK g b(Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grader
Material of construction!concreteametal4(#FiberglassaPolyethylene4L#other(explain)
Dimensions: '
Capacity: gallons
Design flow: gallons/day
Alarm present "-
Alarm level: Alarm in working order:Yes&&NAW,
Date of previous pumping: -0
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.), .
Tight or holding tankg qrp not pre-
gent-DISTRIBUTION BOX: '
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments: -
(note-it level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box, etc.) - —
Distribution box has onp lateral Nn pviripnrp of enIiric rarrti
nvpr NLLemi danra of 3 Q;akaSB I a t 9 9.• out 9f r;he box . �
PUMP CHAMBER.Al
(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.)
-Rump chamber is not present -
revised 9/2/98 Page 8 of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r i
PART C
SYSTEM INFORMATION(continued)
Property Address: 75 Scudder Road Osterville ,Mass .
Owner: Lou Enrich
Data of Inspection: 4/14/9 9
SOIL ABSORPTION SYSTEM(SAS)
(locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits,number:
leaching chambers, number: e��T�ti i ZG
leaching galleries,number:_
leaching trenches, number,length:
leaching fields, number, dimensions:
29-- _
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
Loamy sand to boney fine sand , No signs of hydraulic fnili,rP
or ponding Sol! is dFyz Vegetatt=ien is neFIflal .
CESSPOOLS:NOArQ.
(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 (cesspool must be pumped as part of inspection)
Cesspools are not present .
Comments:
(note condition of soil, signs of hydraulic failure,level of.pending,condition of.vegetation, etc.)
esspoo s are not present .
PRIVY:Abm"_
(locate on site plan)
Materjals of construction: /l// Dimensions: A0
Depth of solids:_
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
:ivy is not present .
revised 9/2/98 . page 9orii
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C r s
SYSTEM INFORMATION (continued)
ProponyAd&—:75 Scud4er Road Osterville .Mass .
Owrw: Louis Emrich
Drta of Eton= 4/14/9 9
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent reference landmarks or benchmark&
locate all wells within 100' (Locate where public water supply comes Into house)
%
2-
®r
• ifs o p 9("
revised 9/2/98 Page toof11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART C
SYSTEM INFORMATION(continued)
Property Address: 75 Scudder Road Osterville ,Mass .
Owner: Louis Emrich
Date of Inspection: 4/14/9 9
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep _
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 6 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
$ Obtained from Design Plans on record
Obseved.Site (Abutting pro art bservation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
—/Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Used Water Contours Map . , '
Gahrety & Miller Model
12/16/94
revised 9/2/98 Page 11of11
e•rnr+rrt.•rsr•rr— rnrm.•ntrrra�nrt asnrr..rr.7++:ttnrr+.r�n.n mrn`ia*rawer.rrA , ..
TOWN OF Barnstable BOARD OF HEALTH J
SUBSURFACE SEHACE DISPOSAL" SYSTEM INSPECTION FORM - PART D •- -CEKTJFICATION
`- ••.Tn-T••.-::f—r.itr.�.T.rnrrm•rf rrf r.n•mTRSRTI9''-'•Ir.tn+r.�le.nvrTnr.'a+n.lf rfriRlTi:sTTi17 .s.n...... rsro-*rrrrrrrr.•.�rrr•Tr-1. —..�
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRESS 75 Scudder Road Ostetville ,-Mass .
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAME Louie Emrth
PART D CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr .
COMPANY NAME J. P.Macomber & So•rf Inc :
COMPANY ADDRESS Box 66 Center.vifle,Mass. 02632 a
street n' Town or CItY state LIP
COMPANY TELEPHONE ( 508 J 775 - 3338 FAX ( 508 1 790'- 1578
CERTIFICATION STATEMENT A
I certify that , I have .personally inspected the. -sewage ''disposa7. system at
this 'address and that the infor►nation reported -is : true, accurate , and
complete as of the time of ,inspection , . The inspection was performed- afid any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience An .the proper function and nia-intenance .of on
site sewage disposal systems .
Check one:
:Sys tern PASSED ;
The inspection which I have conducted has not found any information
which indicates that the�- system `fails° to' a`deQuatel,v protect, public..
health or the environment as 'defined in 310 CMR_ 16 . 303 . Any failure'
criteria not evaluated are as . stated in the-, FAILURE `CRITERIA section of
this form , � .
System FAILED*
The inspection which I have con trc'ted has found that the- system' fails to
Protect the j)ublic health and the environment in accordance with Title
5 , 310 CMR 15 , 303, and as specifically noted on PART-C - FAILURE'
CRITERIA of this inspection form .
Inspector Signature Date,
°One copy of ttlis c t.ification must be provided to the OWNER, the BUYER
( where applioable ) and the D0ARD OF MEAL1'Ii.
If the inspection FAILED, 'the owner or operator aKaII upgrade ' the ayatem
within one year -of the date of the inspection , -unless allowed or required .
otherwise as provided in 3.10 CMR 16 . 305 .
partd.doc
r ..
4• TOWN OF BARNSTABLE
LOCraTION '7 S SCy di e T Z� SEWAGE l �
JILLAGEQSr sit `l ASSESSOR'S MAP 61 LOT, to., �.
.INSTALLER'S NAME & PHONE.NO.
SEPTIC TANK CAPACITY S'C�C7
LEACHING FACILITY:(iype) (size)
.IO. OF BEDROOMS • PRIVATE WELL OR PUBLIC WATER
R OR OWNER
DATE PERMIT ISSUED:
:)ATE COMPLIANCE ISSUED: 140 ;?16
VARIANCE GRANTED: Yes No
TIC)
:;,. .. .
��. . � - .
� _
I �
�,I .,
rn �� �1
i�l� � � -�
��.
�, -,
� � _ '
,.
-,
�k�
Op i �.
Y' �\ ,\
w9� ��
�, ^,�
� � �
\ �'
� \.
�. \•
�\�
s
No....
7 Fx ............3 0: 0..
.
a
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BAgNSTABLE
Appliratimn for Diripwiai Wor1w Tomitrurthin lirrutit
Application is hereby made for a Permit to Construct ( ) or Repair AA an Individual Sewage Disposal
Syst T�at cudder Road Osterville,Mass .
..........................•---•--.....------------------....--------------••-•--------•---..------ -------•-------••----•-••-----...................................................................
Location-Address or Lot No.
Emrich
......................_.......................................................................... ---•-----•--•-•-----------•-----•-------------•-----•---...-••••-....._-----••---...........--•••-
Owner Address
a ........d-: '-s-Ma-e-e-m-ber---ir-=------------------------------------------••. ..................................................................................................
Installer Address
UType of Building Size Lot............................Sq. feet
Dwellini—No. of Bedrooms..-.-.-..•.-.3-----------------------------Expansion Attic (NO) Garbage Grinder (70)
aOther—Type of Building ---------------------------- No. of persons_--------1-----.-.-..--.- Showers (2 ) — CafeterlaN(an6
Q Other fixtures 2._water close-ts----2--s n-ks,...Ki-t-then --s-3nIk----•-----------------------------•---• -
W Design Flow.....1.1.0---------------------------*_-_gallons per person per day. Total daily flow--------------33Q......................gallons.
04 Septic Tank—Liquid capacity -.gallons Length�.o-t�.F4-- Width.rj.1.�P..... Diameter................ De th._.5-i.
xDisposal Trench—No. ...1--------------- Width..13........----- Total;Length.3.0 8........ Total leaching area-3_ !.9.a.sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area......__..........sq. ft.
Z Other Distribution box XX) Dosing tank ( )
Percolation Test Results Performed by--------------------- -•---••--•--•-----•---•-----------•----••----------- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit........------_---. Depth to ground water---_------------------
44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.....---------..._------
0r' ....------•-------------------------------•---••-•-•-----.............._--••••-•••-------•-•......--.........................................................
0 Description of Soil..................................................................-......................................................................................................
v Sand & gravel
W
VNature of Repairs or Alterations=Answer when applicable..Omit....cess.p_o_ols-.....Install___one....1_5.00__-
_gallon_._tank_,-1_-di_stribut_ion___box 1__-__ leaching__trench___13lx30 8-!______ __
---•--•••..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has e a is ed by e oard of health.
Signed - /'---- .......1..0.�.1.. 9 5
Application.Approved By ... . ........ -- --- -------- - -G ---------------------------------.-----.---------------.--. --------- --...�®...`.6�
Date
Application.Disapproved for the following reasons: ----------------------- ------------------------------------- --------- ----------------- ......
----------------_----------------:----------------------------------------....--------------------------------------------------- -----
Permit No. ....... �..'.Issued ..I
.............. [e
ate
t g
No....... 7-. F�$...... ....3.0.00
.�
THE'COMMONWEALTH OF MASSACHUSETTS _
t
BOARD OF HEALTH
TOWN OF BARNSTABLE
' Appliration for Di-tiiaimal Works Towitrurtion Prrmit
Application is hereby made for a Permit to Construct (, ) or RepairXX)xan Individual Sewage Disposal
SystT,atScudder Road Osterville,Mass. ,1,114
..........`-....................................................................................... ---••---•---•-•---••------•••------•----••-•----••------------..._.... ..................
2 ch Location-Address or Lot No.Emri
......................_.......................................................................... -----------------•--•-----•-----•---•-•----•-•--•... .--•........_.......---•••-----
Owner Address �.-
TD 2R.,.. r»har fiT ------------------------------------------•-- ---------•-------•------------------------••---------•------------- ------
Installer Address .`
Type of Building Size Lot__________________________ Sq. feet
DwellingX— No. of Bedrooms.__.__.__-.--____________________________Expansion.Attic (NO) Garbage Grinder (aO)
p`4.I Other—Type of Building ---------------------------- No. of persons-----------1--------------- Showers (2 ) — CafeteriaN(rin,)j
p•I ..Other# QW fixtures�.; �,w..m..�. Irv;.:---avv-i- v- _.ca•..:.
.--.-_..........................................
Desl n Flow.....1 0- ,;----------_
{._.gallons per person per day. Total daily flow______________13Q_.__......_._........
gallons.
' W Septic Tank—Liquid capacity?.-r�-O�_.gallons ,Length]-�a_K.t•__ Width K!--81!----- Diameter________________ Depth..9_L"!Et_.
x Disposal Trench--No:.._1............... Width..1. -_.._.___--.. Total Length- d.g__-.---- Total leaching area_.3....81...9sq, ft.
Seepage Pit No................:.... Diameter----------.--------- Deptjj below inlet-------------------- Total leaching area..................sq. ft.
z Other Distribution box (y�X) Dosing tank ( ')
`" Percolation Test Results Performed by-------- ----------------------------------------------------------------- Date........................................
Test Pit No. I-----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water---
ri Test Pit No. 2................minutes per inch Depth of Test Pit._._-.-.--______-_- Depth to ground water........................
O
Description of Soil -= --- ----------- _t
x .._....and---&..gavel...
W
x
U Nature of Repairs or Alterations—Answer when applicable.-OMt_:cesspaols-._---Ins tal.l---.-..on -_1d0e -� :.
.9411on...tankti.-dlsr but .anbox 1- ---laachln9- trench-1.3 'x30,8'. --
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with r
the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the ,
system in operation until a Certificate of Compliance hase•n issued by e board of health.
��
Sined ----- ...................... 1.a/1 b1.9. ....
Application.Approved By ........ --------------------- ---.....-....---------------------------------.-----------------... ---- ----
Date
Application.Disapproved for the following reasons: ------------------------------------------------------------------------------.......................................................
------------------- gg -----------------------------------------
j .!� .... -----------------
Dare
Permit No. ---------------------------------- Issued !
,--------------------------------------
Dale
J
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
�* Certi iratr of (11omplinurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired TKX )
by . ...T.x R.Iv.aaomber----Jr-------------------_.--- -----------------------.._......------------...----------- --- --------------------------------------------------------------------------------
at ......75.... cu3der...Road----0s.tervil.1.e_ Naas 8- -- ---------------------------------------------- ------....._................ -
has been installed in accordance with the provisions of TITLE o-L The State Environmental Code as de cribed in
the application for Disposal Works Construction Permit No. ./_.742.2 ....... dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILLIFUNCTION SATISFACTORY. �� ��4�/��
DATE........ "'.."� ...`^.._.� ? Inspector ... .. ---
{ r4 r.
THE COMMONWEALTH OF MASSACHUSETTS T t
r
BOARD OF HEALTH
TOWN OF BARNSTABLE FEE.- ....3.0_.
No........................ -- ._._.......... _
- �i��rn�siil �rk� �rra��t�itrtuan rrmit
t ' Permission is hereby granted..J< .PRMa0r1m'bRr---, r---------------------------------------------------------------------
to Construct ( ) or Repair (LX) an Individual Sewage Disposal System
at No..7-5...Seu er...o—a ---Me.ter_VJ,1.1_.R =-------------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit Street
----- Dated------ f/....!......._......__.
/� .................... Board of Health
DATE................ -•----._..._ -
FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS
1- Dis+ 3-330 Pre Char er
28 'x13 ' with 2 ' '
i
1 -1500 gallon septic tank,: ® invert
pa
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
0
I, J.P.Macomber Jr. , hereby certify that the application for disposal works
construction permit signed by me dated 10/16/9 5 concerning the
property located at 75 Scudder Road Osterville ,Mass . meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is `4 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
4 .
• There are no variances requested or needed.
SIGNED : DATE: 1 0/1 6/9 5
LICEN SEPTIC SYSTEM INSTALLER/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];
o
ul
cle
12'-1 3/4° I 13'-0 1/8, 10'-2 1/8°
PLAY ROOM "
BALCONY
U L/ CRAWL SPACE I lk
J 2" CONc. DUST CAP4
° 12�_P. _
o II o EXISTING FOUNDATION
N BEDROOI"1 #3� ` - -_' BEDROOI"i #4 A 8x16 VENT I I
cl
8"z 45" CONCRETE WALL
tb ,. Ib"x10" CONTINUOUS FOOTING
2446 (z 2446 2446'
r_ I
n I ic.
14'-11 1/2" T-4 1/2" 6'-b° ' - -
SECOND FLOOR PLAN
,4a
SCALE: I/4" = 1'-0" 41 tI ,
RIDGE VENT / '4 1.U
2x12 RIDGE BOARD
.Q.RCNITECTURAL GRADE ASPHALT SHINGLES / �'1 ° '•" ® -
5/8" GDX PLYWOOD SHEATHING
R30 F.G. INSUL.
Q
12
o r\eo.
2x4 EXT. STUDS @ Ib" O.G. 12
/6. '
1/2' CDx PLY. 5HEATHING � ATTIC �c J
TYVEK (OR EQ.) / R13 F.G. INSUL _ -
W.C, SHINGLES .. ..
_ W
-2x815 I(" O.G. I - ( ,= L------ llJ
U ~
w V
Q CRAWL SPACE n ° I I BULKHEAD
2" CONG. DUST CAP r N �-° I I DOOR I ,�' ," N tLi
tu
SECOND FLOOR' a i .; I m �' ° i L————J I (L/ Lu Z
8°x 45" CONCRETE WALL m
- V1c'
"x10" CONTINUOUS FOOTING FSxib VENT —— ENT rS
2x10's Ib°O.C... __. — —— '•�-•. ————————— — ——F- ':e:S - _ '- :rr.;.y.;:�:^__:=:=4.a'3 ,
FIRST FLOOR 1 `
FOUNDATION PLAN -
SCALE: 1/4" = 1'-O"
1 2x8's Ib° O.C. - - I SHEET �
3-2xI2 GIRT - A
UNDER HEARING WALL -
u11�-I�1��T1�� CRAWL SPACE w w-u�
-4GIII`II 2" CONC. DUST CAP ' II1=1IkItL'
Ir EXISTING m 11 wT�1_
JOB: 0207
DRAWN BY: KW .
DATE: 9/5/02
,
. "
Flo
12'-0° C i'DEC a 1
_ - FWG 7282 CU15
. . •. . � o o REF.
ANTRY
KITCHEN 1
SFJOWER
SCREENED PORG!!
IL
.. _ FWP 7282all
F I R5T F •LOOK PLAN
SCALE: VA" 1'-0" ` (Y [SI/1f
6 ��vUl
UP Sn -- - -
o Q
a - - 4'-Il° s'-10 1/2° 26 B'-u r12 - -- rl-i
7_bn.. N
BAT" #2 Uo J COVERED = e0
+ - OP RCN 26 \ —(� iv 2Q LIJJ. _ U (n101
r t
A N #i - z4
1 0 to
` I r zi ff Z
E2' 4' 6 7 1/2" 12'-2
a COVERED
GARAGE o w sQ MASTER - W
ATIO m * BEDROOM v
- BEDROOM #2 cv Y EJ
Al
2 '
no24-06 - 2 +
In
off. rv
2446 - / r ` .
H 17
2 JA
SEET
o
20'-0* yr / JOB: 020" -
DRAWN 8Y: KI"
^I+"� DATE: 9/E -
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hPOWEll SG c- � 4 G�StT FL_���•Y
___ — ----.. -..... .. .......__ . — _------�j• 1 �-
y ar
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i
a
�F.�i.�. .,.fir. •�.; /�o'.I � -- psi �Y
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— BARNSTABLE
NOTE- ELEVATIONS SURVEYED AND MATCHED WITH G.IS
5 /
O LOCUS c 9y'1'o 9
EXISTING 'A TLn
3 CULTEC RECHARGERS o
t (PER INSTALLERS CARD) 0 9�
INSTALLED 10120195
BY J.P. MACOMBER '
PERMIT 195-1775 375, 295 QQ oe Po s
16�53 WAY s2
A,M• 1 IGKT OF
20
LOCUS MAP
yg
151 q6' \ o f?5 AgFA
ASSESSORS MAP- 140, LOT 18
IP
PLAN REF 37141 & DEED
o C 30.0 ZONING. ..RC,.
10 6• ° 2 0 �� FLOOD ZONE. ..0..
vEN 6 of A� O '� I'
or
i s /� G ,.c�j GROUNDWATER PROTECTION
ss ovso 20.3
° N y P� 0 VERLA Y DISTRICT "AP"
0
PAR. 1 �6 yp° 18.5 -p p E 1014 c
v Ii o ADD Q
E 4 - ��AZ
SITE AND SEWAGE' PLAN
35 3 N 8
20 T.O.F= 31.3's.o' :v t}Q OF LAND
f io.oI 0,- j LOCATED AT '
DOCK
75 SCUDDER ROAD
tv 10•4' 7 ` : BRUCE �, OSTERVILLE, MA.
ls. 3 ' .;
0 vs 7r 61. 1 G. ,.
�' / q 1 cs MURPHY H
No. 749
PREPARED FOR
5.9 ► s�F01STfR �a
AS/LOT 54 N/TARP PEACOCK & CROSBY
PORTION OF LAND A. M. 14 01-18
ADDED 770 PAR 1
DEEP- 122861144 � DECEMBER 11, 2002
AREA OF
28,396 S.F. —
`�.��Q�tp........, ao�o SCALE.• 1" — 30'
N/F 2.' PAUL A.
LUKENS, DONALD N. p _�? MER"EW
& ELIZABETH E. =o= 32098
YANKEE SURVEY CONSULTANTS .
UNIT 1, 4 0B INDUSTRY ROAD
20.01 79.99' ► ' � rerrt P. O. BOX ,265
103. 70' By DEED 1 I MARSTONS MILLS, MASS. 02648
168-69' TEL- 428-0055 FAX 420-5553
583,22'30"W �' 15.00'. .
PAR 2 .
- PAR A2 r� 53199 Dce
PLAN 115141
"
•
EL. =_31.3
TOP OF FOUNDATION
- 20 MIN. VENT REQUIRED
10' MIN. CONCRETE COVERS
# 4" SCHEDULE 40 P. VC
MIN. PITCH 118 PER FT. 2"LA YER OF
�
CONCRETE COVER
WASHED S719NE
B MAX / r/ r/ r/ r / r r r / r r / / 30.0
- B A/AX 4, / / 8 MAXi / / 8 MAX
4" CAST IRON PIPE
+ P�RL^H��4 a ER/ CLEAN
FT RISER SAND ~
FLOW LINE f 26.5
INVERT 1MIN, 4-1
EL.= 28 3 _ GASINVERT LEVEL o 0 0 o a o 0 0 0 0 0 o° tV
BAFFLE _27 75 t INVERT 6" SUMP INVERT o 00 0 0 0 0 0 0 0 0 0 �o o = 23. 75
INVERT EL.---_ —,Z7 5
EL._ O EL. ----- NEW EL.—27 25 .INVERT 4 I 4'
1500 _ GALLONS DISTRIBUTION EL.=,9
BOX (DB—9) to
PROPOSED SEPTIC TANK TO BE WATER TESTED -33.5' X 12.8' TRENCH FORMATIO � 00
6" STONE OR COMPACT IF MORE THAN ONE OUTLET cb O
PLACE ON s" s7YJNE SOIL ABSORPTION
PROFILE OF DOUBLEEWASHED/STONE SYSTEM (SAS)
s SEWAGE DISPOSAL SYSTEM NO OBSERVED WATER TABLE (11127102) ELEV.=_I_5.0
NOT TO SCALE USGS PROBABLE WATER TABLE ELEV.=_14-9
G.LS CORNER OF MAIN STREET & EAST BAY ROAD ELEV.= 10_7_--__
PERCOLATION RATE __<2 MIN./ INCH AT 48__ INCHES
OBSER PA TION HOLE I ELEV.= 30.0_
RECONNECT NEW DB-9 D—BOX DEPTH HORIZ TEXTURE COLOR MOTT. OTHER
TO EXISTING SYSTEM, VERIFY ELEVATIONS 0-107 A SANDY LOAM IOYR-3-2
PRIOR TO CONSTRUCTION U.S.C S. ADJ
10 —42 B LOAMY SAND 10 YR—6.8
42"-15' Cl MEDIUM SAND 10 YR—8.4 PERK WELL MI W 29
ZONE B
ADJ. 4.2
OCT. .2002
GENERAL NOTES NO WATER
1) ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. P #' = 10,356 SOIL TEST
TITLE 5 AND THE TOWN OF _$,4RN,FTABLE---- RULES AND
REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. DATE OF SOIL TEST 11127102 SOIL TEST DONE BY BRUCE C MURPHY, R.S.
2) ONE COVER ON SEPTIC TANK SHALL BE BROUGHT TO WITNESSED BY: DA VE STANTON
WITHIN 6" OF FINISHED GRADE, OTHERS WITHIN 12
3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF
WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN ,r)
10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE DESIGN CALCULA TIONS.'
USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. 4
4) ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL INSTALL. THREE (3) ACME NUMBER OF BEDROOMS . .
500 GALLON LEACHING CHAMBERS GARBAGE DISPOSAL NO
BE MORTERED IN PLACE.
5) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH WITH FOUR FEET OF DOUBLE TOTAL EGAL/BR. FLOW
10 440 GAL/DAY
DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO WASHED STONE SIDES AND ENDS ( /DA Y x __4_ BR)
OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. 33.5 X 12.8 EXISTING SEPTIC TANK CAPACITY 1500 CAL
6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR RECONNECT NEW DR-9 D-BOX. SOIL CLASSIFICATION . . . . . . . 1
IS TO CALL DIG- SAFE" AT 1-800-322-4844 AT LEAST 72 HOURS TO EXISTING SYSTEM, VERIFY ELEVATIONS DESIGN PERCOLATION RATE < 2 MIN/IN.
PRIOR TO COMMENCING WORK ON SITE. PRIOR TO CONSTRUCTION ,, EFFLUENT LOADING RATE . . . . . .74 GALIDA Y/S.F.
7) CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS. LEACHING CAPACITY (AREA X RATE) 454 GAL/DAY
SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. RESERVE LEACHING CAPACITY . 454 CAL/DAY
8) PARCEL IS IN FLOOD ZONE___'C"------ (33.5X12.BX74)t(33.5f33.5+12.ef12.B)X2X74)'
9) LOT IS SHOWN ON ASSESSORS MAP _L411 AS PARCEL PACE 2 OF 2 JOB 531y8