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0169 SCUDDER ROAD - Health
169 SCUDDER ROAD Osterville A = 140 - 010 'II i a 0 f� Commonwealth of Massachusetts Title 5 Official Inspection Form �l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1.,_•T, , 169 Scudder Rd Property Address Susan Sipple Owner Owner's Name information is ✓ x required for every Osteryille MA 02655 6-7-19 1?. page. City/Town State Zip Code Date of Inspection «s 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. Inspector Information 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 that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal system of theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes rs 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 6-7-19 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 r Commonwealth of Massachusetts " Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 169 Scudder Rd Property Address Susan Sipple Owner Owner's Name information is recuired for every Osteryille MA 02655 6-7-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes:. I have not found an information which indicates that an of th® y y e 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. 2) 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. p System will ass Y 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): tEinsp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i.) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 169 Scudder Rd _ Property Address Susan Sipple Owner Owner's Name information is required for every Osterville MA 02655 6-7-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. f ❑ 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 ❑ Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y '❑N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑Y F. N ❑ ND,(Explain below): i ❑ 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 El ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 169 Scudder Rd Property Address Susan Sipple Owner Owner's Name information is required for every Osterville MA 02655 6-7-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**: Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.M612016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts r� Title 5 Official .Inspection Form hi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 169 Scudder Rd Property Address Susan Sipple Owner Owner's Name information is required for every Osterville MA 02655 6-7-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. D. ® 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. 5) 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form w_� ri Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 169 Scudder Rd Property Address Susan Sipple Owner Owner's Name information is required for every Osterville MA 02655 6-7-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Wasthe 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts f. Title 5 Official Inspection Form i�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 169 Scudder Rd Property Address Susan Sipple Owner Owner's Name information is required for every Osteryille MA 02655 6-7-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): . 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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: • r . t Sump pump? ❑ Yes ® No Last date of occupancy: 6-2019 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form �.i �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 1 169 Scudder Rd Property Address Susan Sipple Owner Owner's Name information is required for every Osterville MA 02655 6-7-19 e. City/Town State Zip Code Date of Inspection i page. p D. System Information cont. Y (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner--pumped 2013 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: New system t5hsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form C�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 169 Scudder Rd w Property Address Susan Sipple Owner Owner's Name information is required for every Osterville MA 02655 6-7-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 2013 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 16"feet Material of construction: " ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts ,l Title 5 Official Inspection Form C�'i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY r W 169 Scudder Rd Property Address Susan Sipple Owner Owner's Name information is required for every Osterville MA 02655 6-7-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 8" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 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. t5insp.doc•rev.7t26l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f Commonwealth of Massachusetts r� ,w Title 5 Official Inspection Form , I-I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments W >" 169 Scudder Rd �r Property Address Susan Sipple Owner Owner's Name information is required for every Osterville MA 02655 6-7-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): , Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.):` 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts 1� Title 5 Official Inspection Form �l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 169 Scudder Rd Property Address Susan Sipple Owner Owner's Name information is required for every Osterville MA 02655 6-7-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) 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 9. 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. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 169 Scudder Rd Property Address Susan Sipple Owner Owner's Name information is required for every Osterville MA 02655 6-7-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 24 Arc 36's ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form r�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r a 169 Scudder Rd Property Address Susan Sipple Owner Owner's Name information is required for every Osterville MA 02655 6-7-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach field in good working order and empty at inspection with no sign of back-up. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form } ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r := ;> 169 Scudder Rd Property Address Susan Sipple Owner Owner's Name information is required for every Osterville MA 02655 6-7-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) k 13. 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 it Commonwealth of Massachusetts Title 5 Official Inspection Form 6,l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments g p Y rY 169 Scudder Rd Property Address Susan Sipple Owner Owner's Name information is required for every Osterville MA 02655 6-7-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately JL L' �P . .A t5irisp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts r� ;w Title 5 Official Inspection Form �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 169 Scudder Rd Property Address Susan Sipple Owner Owner's Name information is required for every Osterville MA 02655 6-7-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. 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: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev..7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 P 9 P Y 9 c Commonwealth of Massachusetts ir Title 5 Official Inspection Form I� wa r�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 169 Scudder Rd Property Address Susan Sipple Owrer Owner's Name information is required for every Osterville MA 02655 6-7-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5ir sp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOE!4F EAIt iST"LE /r �CG��d�s' �cl SEWAGE W. ASSESSOR'S lk ',3clGOT VILL�t;F_-------- 3h TA3.LER`g AIA11► c�k pHOM N4 SEP'!LC TANK CAAGTCX /► j ?SEA._.. .. .. NOFBEUGOI�I[S �UtLDER OR tlWi�ER PEIITI�ATE. Gi3tv€ L1AIdCE DATE:' Seperat�on Drstancc Be�arastti Ede : t Mau ium rousted Groatsr TahIe to the Bottom ofI.eaching Facility Pr 'WAY. :Supply�$11 andii ►o F�`�► (��Y on sits or ant�un?AO feet of teacluag f��y) Edge q£�lEtlaad andI eaclungat)`(�fY�vetlaiids exist within 300'fee :teactung faalnY3 �Yz... / PC,(k � b d � 6'd- ��� TOWN OF BARNSTABLE LOIvATION SCUCfekr &CJ SEWAGE# 20t 3 - Z. 1i V,IftAG.E C�)S'k*-trV ASSESSOR'S MAP&PARCEL/ INSTALLER'S NAME&PHONE NO.t-pew.-A, E ,rori= ac m -6t-y77 JT7j SEPTIC TANK CAPACITY qq LEACHING FACILITY.(type)dJ 64K,36 HQ m!! tp (size) /1, 5)( 3 NO.OF BEDROOMS 3 OWNER C l at.,re i c, .1. PERMIT DATE: &'i 1' Lo 13 COMPLIANCE DATE: Separation Distance Between the: c,Vy#g�. coin Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility A* Vig� 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 Of any wetlands exist within 300 feet of leaching facility) YA la! Feet FURNISHED BY Gt V, lr Ol� ��l.! No. 2"13—2116 Fee r� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftplitation for Mispo8al 6pstem Construction Permit Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ((Oct SC_QM(21Z R0d4U Owner's Name,Address,and Tel.No. t �� 0STC—V_ iLLC_ CcALIDL , r���l Assessor'sMap/Parcel "T� 10 lug 5<10-bDdr, la-b 6P_L1t ,(1✓ Installer's Name,Address,and Te o. �9 4`1'1°-�91 T�?Designer's Name,Address,and Tel.No. 5bR-;" -o?,j t 5 3 S W4-ksf+v66 E► (e. Z ENS Type of Building: Dwelling No.of Bedrooms Lot Size 12 ;-L 4 sq.ft. Garbage Grinder( ) Other Type of Building No.L�t 'C1i��✓ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 4 4 gpd Plan Date .Z 176.,[✓ G, aO L3 Number of sheets I Revision Date Title t( ct SG VODER RC AD Size of Septic Tank i OCXD C—ikjtLZjJ Type of S.A.S. ..gRgj4EJ� Description of Soil 1/k Gp l ykG c z o `I J1r� QC�1 Nature of Repairs or Alterations(Answer when applicable) Q S E E j.S-CC hn :e, L,Co C^�¢E[-p0 _M Dy61A_) D-90K, 7R) o14 &C 3( RC R1001iEvs&S 0-) A '=t tS%� <aJr(O z7 O tj 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 Certificate of Compliance has been issued by this Board of Hea ed Date (6- I rl 40 L 3 Application Approved by Date ell?12vg Application Disapproved y Date for the following reasons Permit No. t�J- alb Date Issued C11�20 0303 1 No.a Z 2. ..w, t f - „ x Fee i computer:Entered in 4, THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -`TOWN OF BARNSTABLE, MASSACHUSETTS Yes f / j application for Mi�poBaY bpstetn ConBICUction Permit Application for a Permit to Construct(1) Repair( :Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. t(,pg Owner's Name,Address and Tel o 0sTev_vr� CcALIDtA =0" 1 E�.VtC.(..� Assessor's Map/Parcel 140110 i SGcJ�D 2 Pv� *5z' In Iler's Name,Address,an e io ��' 1 Des' ner's Name,Address and Tel�.h G FS o�`T3—Oj'I Ci�PEu�'�E 153 CC)14.eoA C-MciA-(_ sC k4vkst+o(56 A,954 6PAT-6G0y Ilk" E, Type of Building: c Dwelling No.of Bedrooms Lot Size I O 1aq4 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ~ ' Design Flow(min.required) gpd Design flow provided 49 gpd Plan Date 3 V W C O j ao 0 Number of sheets Revision Date Title I(per'( J56 LAJ_D40,> _R0 '`/ 4>S_6Eq>_lf1 U_Je_ + Size of Septic Tank 10CQ Type of S.A.S. P,4 AO�, Description of Soil JAI G L.,, 5e-c— CCAhJ Nature`of Repairs or Alterations(Answer when applicable) USE ETC!ST( 1, C 1C20 644.100 St:�PY`<. `l -o- I ,-M &J&gj -D--60K 4 #40,C .36 1EG 810DI:F:FUSt_X,S 11-J A ' p 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 Certificate of Compliance has been issued by this Board of He e ! ed Date Application Approved by Date 3 !L fa Application Disapproved b Date _ PP PP Y - for the following reasons ' ` Permit No. 001 b (�6 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired 00 Upgraded( ) Abandoned( )by CA9GWIb� ��9�RsS 5 'ux ,. at 5 L ��� � � �S (LC�has been constructed in accordance with the provisions of Title 5 and the for Disposal System j' �Co�nsst-r+uction Permit No.�13-71` dated /� 2�1j Installer COO&W(.0E �3ZW9199 LLC Designer G #bedrooms Approved design flow ( /Y gpd The issuance of this p t no a co t ed as a guarantee that the system w` fun ti %de/sig/ne f !✓ f Date � Inspector No. 13 2 Fee �� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction i3ermit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at I 9 5 c1nb ek Rd 4D�y1� y b C and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. i Provided:C nsttrruc ion must be completed within three years of the date of this perm' . r— Date ��7 ?O 13 Approved by I ■ 007/03/2013 02 :41. 5082730367 42264 P. 001/001 ONE Town of Barnstable Regulatory Services Thomas F.Geiler,Director ' BARMARM Public Health Division MABB. Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office- 508-862-4644 Fax. 509-790-6304 Date: a 1 a oi3 Sewage Permit# a of 3 .2 Ile Assessor's Map/Parcel 0 I o Installer& Designer Certification Form Designer: Installer• r—decw;de eov"erfse_S Address: 2854 Csenti4 r� 4.5hwoy Address: 15 �os1 W0(6nc - t1A o253$ ; 6-273-6377 �— On (a 1�1-aOl3 �•�pEa.�1CA5'r--KttER as issued a permit to install a (date) (installer) septic system at 169 ScuolAer R4g� US�trV1 ale based on a design drawn by (address) -:S C E n gl 06e-(,n5 Toc_ dated June' )3u a a z 3 (designer) I certify that the septic system referenced above wasinstalled substantially according to the design, which may include minor approved changes such as I4teral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required) pected and the.soils were found satisfactory. JOHN L. CHURCNILL � (I ler's Signa re) iviL . 41eo esigner s Signature (Affix De gi Here), P ASE RETURN TO ARNSTABLE PUBLIC HE DIVISION.. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTY BOTH JUIS )FORM AND AS BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. q!\office formAdesignercertification form.doe Town of Barnstable P# Department of Regulatory Services I MAW r Public Health Division Date V 4 i639 200 Main Street,Hyannis MA 02601 lEp A / Date Scheduled �G Time Fee Pd. Soi Suita iii ' Assessment fog- Sewage isposal eof �ra le I Performed By._ b ET 1 CS J L- Witnessed By: LOCATION& GENERAL INFORMATION Location Address �� SGv��2v2 �A4 DSfi�t�tl.L� Owner's Name Address S C vcxa(� ILl) Assessor's Map/Parcel: !q010, 0( 0 Engineer's Name cv L,, NEW CONSTRUCTION' REPAIR Telephone# `t-1, VV-7 7 Land Use: KL51dfACk( Slopes(%) 0-3 Surface Stones Distances from: Open Water Body > 100 ft Possible Wet Area 2100 ft Drinking Water Well , I V ft Draihage Way ft Property Llne > >0 ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands In proximity to holes) Rear 36 El(. t4nk 3f`1 30 Parent material(geologic) Depth to Bedrock > li p GS Depth to Groundwater. Standing Water in Hole: /V O11 e— Weeping from Pit FACC Ott e Estimated Seasonal High Groundwater a� GS DETERMINATION FOR SEASONAL HI Method Used: GH WATER TABLE Depth Observed standing in obs.hole: In, Depth to soil mottles: Depth to weeping from side of obs.hole: In, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level :_ Adj.factor_ Adj.Groundwater level PERCOLATION TEST Data 6 1U 13 mwo lb 4M Observation Hole# Time at 4" _ Depth of Pere 3• — 0 tt 36'6q' Time at 6" Start Pre-soak Time @ 1 Q t a2® to-34 Time(V-0) End Pre-soak �D.'a�O 1 't]i qq Rate MindInch Mi h 1 to Site Suitability Assessment: Site Passed _ Site Failed: Additional Testing Needed(YIN) r y Original: Public Health Division Observation Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. ! Barnstable Conservation Division at least one(1)week prior to beginning. Q:\S EPTICVERCFORM.DO C DEEP.OBSERVATION HOLE LOG Hole# 1 -f a Depth from Soil Horizon Soil Texture .Sdil Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,'Boulders, Cosisten1:;y,.%Drivel) 0— O LS 1Dyk 3 a 0-36 6 LrS 1 o YQ 30-Sa C I N F--M Say,4. a,S-y 613 ;x DEEP OBSERVATION HOLE LOG Hole#_3i, q Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders, o sis en %Gra e —� 1001 2 10'fk (v 36 N _V_109. 601 F Su, a,sY 613 109-1 a 0 C 3 -C Say, �I YY 6/3 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders, Consistency, a Flood Insurance Rate Map: Above 500 year Hood boundary No=— Yes 4 Within 500 year boundary No f Yes ' Within 100 year flood boundary No. Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious mtiterial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious matorial? _ Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expertise apoexperience described in 110 CMR 15.017. Signature /J �2� Date ro l d Q:15.EPT1C�PERCF0RM.D0C 1 y: Town of Barnstable Barnstable OF THE Tp� Regulatory Services Department 'erica�i + sa MA:§S.LE,o! public Health Division - 9 MASS.NSTA0 �A 1639. rF°M"`N. 200 Main Street,Hyannis MA 02601 ?oo� Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010 0000 2850 9132 May 28, 2013 Mr. & Mrs. Daniel Mahoney 169 Scudder Road Osterville, MA 02655 • ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 169 Scudder Road. Osterville, MA was last inspected on 4/18/2013 by Patrick M. O'Connell, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following, • System is in hydraulic Failure You are ordered to repair or replace the septic system within sixty (60) days from the.date you receive this notification. . Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH I • a Thomas McKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\169 Scudder Rd Ost May2013.doc Health Master Detail http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=140010 '"ir r'Y +� 77".,,.�,,,--z4n,✓.ada _ ALL*A-� 4. .• ; - `" ` Logged In As: TOWN\flynni Health Master Detail Tuesday, May 28 2013 Application Center Parcel Lookup Selection Items Reports Parcel Septic Perc Well Fuel Tank Parcel: 140-010 Location: 169 SCUDDER ROAD, OSTERVILLE Owner: MAHONEY, DANIEL G &CLAUDIA I Business name: Business phone:l � Rental property: r Deed restricted: ❑ Number of bedrooms : 0 Contaminant released: r Fuel storage tank permit: r Save Parcel Changes � 7 a Return'to Lookups Parcel Info Parcel ID: 140-010 Developer lot:LOT7 Location: 169 SCUDDER ROAD Primary frontage: 100 Secondary road: Secondary frontage: Village:OSTERVILLE Fire district:C-O-MM Town sewer exists at this address: No Road index: 1442 Asbuilt Septic Scan: 140010_1 Interactive map Town zone of contribution:AP (Aquifer Protection Overlay District) State zone of contribution:OUT Owner Info Owner: MAHONEY, DANIEL G &CLAUDIA I Co-Owner:%MAHONEY, CLAUDIA I Streets: 169 SCUDDER ROAD Street2: City:OSTERVILLE State:MA Zip: 02655 Country: Deed date:9/16/1974 Deed reference:2096/323 Land Info Acres: 0.42 Use: Single Fam MDL-01 Zoning:RC Neighborhood: 0111 Topography:Level Road:Paved Utilities:Public Water,Gas,Septic Location: Construction Info Building No ear Buil Gross Area Living Area Bedrooms Bathrooms 1 1952 668 1676 3 Bedroom 2 Full Buildings value:$134,100.00 Extra features: $36,000.00 Land value: $355,300.00 http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=140010 5/28/2013 a L f Commonwealth of Massachusetts 34 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 169 Scudder Road Property Address Mahoney _ — Owner Owner's Name information is Osterville _MA 02655 April 18, 2013 required for every page. City/Town State Zip Code Date.,,.f Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the , computer,use 1. Inspector: only the tab key to move your pO'Connell atncl�M. cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name r� 189 Cammett Road Company Address Marstons Mills MA 02648 renm CityrTown State. Zip Code . — 508.428.1779 SI12855 ' — Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: `L, ❑ Passes ❑. Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Loca[Approving Authority . Aril 18 2013 Job# 13-28 Ate. p Cy Inspector's Signature - Date ' _: The system inspector shall submit a copy of this inspection report to the Approving Authority (Board t-- of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or U-.14 b:--has a deign 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 ant to the system owner t and,copi's,sent to the buyer, if applicable, and the approving authority. y """ 9 � """this repjrt:only describes conditions at the time of inspection and under the conditions of use © Ept that tiW,%This inspection does not address how the system will perform in the future under F" the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1 of 17 J 5115 1 9 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 169 Scudder Road — Property Address , Mahoney — Owner Owner's Name information is MA 02655 A 18, 2013 Osterville required for p t - every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of'Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: • B) System Conditionally Passes: ` E ❑ 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): r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 . N At Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 169 Scudder Road — Property Address Mahoney Owner Owner's Name information is Osterville MA 02655 April 18, 2013 required for -- ., 4 Zi Code Date of Inspection every page. City/Town State P B. Certification cont. i ❑ Pump Chamber pumps/alarms not operational.YSystem will pass with Board of Health approval if , pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if`(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ NJ (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑. Y ❑ N ❑ ND (Explain below): J ' ❑ The system required pumping more than 4 times a year due to broken;-".'obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): , ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,_safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: f ❑ 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 ~ Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1 ' 169 Scudder Road -- Property Address , Mahoney Owner Owner's Name information is Osterville MA 02655 April 18, 2013 required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) ' 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. Cl The..system has a septic tank and SAS and.the SAS is within a Zone 1 of a public water, supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: { ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. ' 3. Other: D) System Fail ure'Criteria Applicable to AI•I Systems: You must indicate "Yes" or"No" to each of the following for all inspet,:'.Jons: Yes' No '. j ® a 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 p , 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 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 4 of 17 t5ins•3/13 e r I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 169 Scudder Road - — Property Address Mahoney —---- Owner Owner's Name information is Osterville MA 02655 April 18, 2013 required for --- every 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'-urface water supply or El EK tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal.coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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. • I 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 Elthe system is located in a nitrogen sensitive area(Interim,WelIhead Protection Area- IWPA) or a mapped Zone Il of a public water:.zupply 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:Subsurt-..e Sewage Disposal System-Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ` \a ' 169 Scudder Road — Property Address Mahoney — Owner Owner's Name information is required for Osterville MA 02655 Aoril 18, 2013 — - every page. City/Town State Zip Code Da. of Inspection C. Checklist Check if the following have been done:You must indicate"yes" or no as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any:of-the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the s},atem recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not', avai'able note as N/A) ® ' ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® El information the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part,C is at issue El approximation of distance :s unacceptable) [310 CMR „.5.302(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 4 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 169 Scudder Road — Property Address Mahoney —. Owner Owner's Name information is Osteryille MA 02655 April 18 2013 — required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: i 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No h 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? ❑ Yes ® No Currently Last date of occupancy: Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? El Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 7 of 17 4. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 169 Scudder Road — Property Address Mahoney — Owner Owner's Name information is Osterville MA 02655 April 18 2013 required for every 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: Tank pumped Nov 2010 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): • r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 169 Scudder Road _ — Property Address Mahone - — Owner Owner's Name information is Cisterville MA 02655 April 18, 2013 _ required for every page. Cityrrown State Zip Code Date of Inspection r D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1988 Were sewage odors detected when arriving at the site?` _ ❑ Yes ® No -Building Sewer(locate on site plan): Depth below grade: , feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting,evidence of leakage,etc.): Septic Tank (locate on site plan): 1 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No. 8.5' long x 5.2'wide- 1000 gal. Dimensions: 3" Sludge depth: _ t5ins•3/13 Title 5 Official Inspection Form:Subsur':=,;e Sewage Disposal System•page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 169 Scudder Road Property Address Mahoney Owner Owner's Name information is Osterville -MA 02655 April18 2013 — required for State Zip Code Date of Inspection every page. City/rown D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 27 . 2„ - Scum thickness 6" Distance from top of scum to top of outlet tee or baffle 12" — Distance from bottom of scum to bottom of outlet tee or baffle -- Measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, ` liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was at bottom of outlet invert observed solids on top of outlet baffle indicating surcharge_ + 4 Grease Trap (locate on site plan):. Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass. ❑ polyeth):-ne ❑ other(explain).- Dimensions: Scum thickness .Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface,Sewage Disposal System•Page 10 of 17 1 F i f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^Mf 169 Scudder Road - Property Address Mahoney -- Owner Owner's Name information is Osterville MA _ 02655 April 18, 2013 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Comments (on pumping recommendations, inlet"and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan). Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: Yes" ❑' No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 11 of 17 t5ins•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form Not for Voluntary Assessments . 169 Scudder Road — Property Address Mahoney — Owner Owner's Name information is Osterville MA 02655 April 18, 2013 _ required for every page. City/Town State Zip Code Date of Inspection — D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 0" — Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Previously full to top. — Pump Chamber(locate on site plan): t 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: 15ins•3113 Title 5 official Inspection Form'Subsurface Sewage Disposal System•Page 12 of 17 p f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . �M 169 Scudder Road Property Address Mahoney Owner Owner's Name information is Osterville MA 02655 April 18, 2013 — required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont) Type: One 6x6 pit. _ ® leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ------------ ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Liquid level was over inlet pipe, pit is in hydraulic failure. -- - s 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 13 of 17 t5ins•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 169 Scudder Road _ Property Address Mahoney Owner Owner's Name information is MA 02655 April 18, 2013 required for OSterville State Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of pondinr; 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.): l5ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts �i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 169 Scudder Road -------- _ —-- ---- Property Address Mahoney Owner Owners Name information is MA 02655 April 18, 2013 Osterville required for - -..__.._._.. p — -------- --- every page. City/Town _ _ _ _ State _ Zip Code Date of Inspection D. System Information (cost.) 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 welts within 100 feet. Locate. where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 35 6 40 y f' ',`-, 71 E Back >ref Yard i . x Y r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 169 Scudder Road — Property Address Mahoney Owner Owner's Name information is MA 02655 April 18 2013 required for Osterville State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) y a Site Exam: ® Check Slope ® Surface water ' ® Check cellar ® Shallow wells N/A ' Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain:' You must describe how you established the high groundwater elevation: t t Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17' t5ins•3113 i Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M 169 Scudder Road _ Property Address Mahone Owner Owner's Name information is Osterville MA 02655 April 18, 2013 required for State Zip Code Dare of Inspection every page. City/Town 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 a r Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 17 of 17 t5ins-3/13 a Vol' TOWN OF BARNSTABLE L(`OCATION��� ����`'-�SEWAGE # Y— 5 Z/ VILLAGE/°Y� c / C -�— ASSESSORS MAP az LOT INSTALLER'S NAME & PHONE NO.(, )0Itq--jL w S SEPTIC TANK CAPACITY f O O LEACHING FACII.ITY:(type)��= 00 G�0 (si7.e) a-��l _ 5f4 NO..OF BEDROOMS PRIVATE WELL OCPUBLIC WATER ) BUILDER OR OWNER _ DATE PERMIT ISSUED: 21 �o DATE COMPLIANCE ISSUED: ��� VARIANCE GRANTED: Yes_ No41---�� � i w r P 1� 1r v + D,Poo( If I q0 —o to <3 No .......�..� Fps ....................... THE COMMONWEALTH OF MASSACHUSETTS r.- BOAR" H EA , I-1 { . r................0F....... �U %� Appliration for Dispas al Wnrkg Tour rurtion rantit Application is hereby made for a Permit to Construct ( ) or Repair (/-j"an Individual Sewage Disposal System at: A.F_11;.,Se C."jz?�110 0�5 Cj .. 0 Locati Address or Lot No. Address{--� _••• .............................•.. ._1�.... �' '........ ...........••••--------•------•----------....--•------- Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) �-+ Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ---------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter-------_-------- Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-.--__.-__--_-_-------_. Grq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.-_-___-__-___--_--_--. 9 ---------••---•••------•---••.............••---•-----------•-•--•-•...-••........---.------------•----------------------------------------------------.------ 0 Description of Soil....................................................................................................-------------------------------------------••--•--•......----.--••- x U --••-----•--------••-•-•-------------•---•---•------•-----•----------------•-•-----.•----.-..----•-•-••----•-•------------•-----------------••------••--•-------•----•---•-----•---•--•--------------- •-----•--....---•----------••---•••••......•-•••-.----- • ••••••••----•-••---••-•-•--•-•-•-•................••-- -- --•--••----• ---•---•••-•--••••......•-- Nature of Repairs or Altera 'o s—_Answer when applicable_. P ---------------- UP .................... �� -- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with f•tT/`1 T•-� the provisions of i 1 i LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha�been7� t o �of healt . / 7 Signe _....-•--•---------•-------- •• Date Application Approved By............... .............•-•------� --------- ----•---- g .... � Date Application Disapproved for the following reasons-----------------------------------------------•---------------•-------------•--------------••-•--•----•--------- .............................•--....-----....---•--•-----..................-----------......-------•-.....__....•------------•--•--•---------•-•-•-•------------•---••----•--------------••---••-------•- �q Date Permit No..&A....----•-`-�-,4 f G ----------•----- Issued--•--------------------------------- - -••_ LSt.. Fms :r......................_ THE COMMMONWEALTH OFUMASSACHUSEETTS BOW) ..............OF.........---...---........�... /�C. � 1F Allp ira#ion for DiiiVog al Workii Tonotrurtion ramit Application is hereby made to a Permit to Construct ( ) or Repair (1-yan Individual Sewage Disposal System at: , //, __------ •................... ......... ------------------•••--•----•---••- -----••----------------- -------------------------- ..:_...---------•---•---- ---------•----------- /y)���y' Lo ati Address or Lot '�o. -- - p w�r /e Address Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures __________________________________ ------------------------------------- •...... .------------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—'_fro..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) `-� Percolation Test Results Performed by.......................................................................... Date........................................ ,4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_---__-____________-__-. rz Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_--------------_----- P4 ---------------------------•--------------------------------------------...........---.....------......---------------------------------------------------•- 0 Description of Soil........................................................................................................................................................................ x U -----•-•-•-••-•-••....-------•..................•--••--•-•-------••••---.......-•-••-----•-......-----•••••••-•••-----------•-------•-•---.....•-••..__................................................ -----------------•-------------•--------------••------------------- -------------•--------------•-----------•----------•---- ........ ............................ U Nature of Repairs or ltera 'o —At}swer when applicable__ �.____/ E''. /.__._.._ ._ .. ,f.-!�'Z...-`............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'IT1.-. p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee 1 Signer ��it'1` .` /� 1 •--- ---------------------- -------------------•-----•--- �Date Application Approved By............... ''`�--..0.. �- 51 Date Application Disapproved for the following reasons-----------------------------------•--------------------•----•-----------------------------.........------•..._._ ..............................................................-•---••--•-------------••.....•--•------...---•-•--...._..•----•--•----•-•-----•-•------•--------•--•--•-•---•••--••••-•-•---•-------•--•. �� ?-- Date PermitNo------------------•------------------ ------------•----. Issued--•--•-•---•-------------••---•---...-------•------•-•- THE COMMONWEALTH OF MASSACHUSETTS BOARD � F HEALTH ......OF... ✓ !....:.: .. r.............P.................. Trrfifiratr aaf Tantlifitturr THIS IS TO •RTIFY, at he Inds idual Sewage Disposal System constructed ( ) or Repaired by �- f....... �.....��..wi.._5�-------------- . /� p�p..�.-.... /�.._. Ins erC G/ �`/ 1 71IS.. at ---.--..... - has been installed in accordance with the provisions of TITIEc� 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.__.......'.s......%...2f....... dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................... ..r'Z O .......................... Inspector...................... --•----------•----•-----•-----..----••---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA T ` (� ...... . ............OF... ................................. Q 0 No..L1.............S.........� FEE........................ �i��tar��1 � �a� ��rtuan rriYttt# Permission is herebyranted....!,!/,_/.. ! ! '. ... .................... _ g ...••--------------------- ......................... to Construct ( ) or Repair ( n Indi id 1 Sewage isp sal System } �/ a" T Srreet Or as shown on the application for Disposal Works Construction Permit No................_.\ Dated.......................................... ----------------------- ------- ---------------------------------------- •------------------- Board of Health DATE......................... FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS T.O.F. EL.= 36.5'± 4"SCHEDULE 40 PVC MIN. SLOPE 1% FINISHED GRADE OVER BIODIFFUSERS = 34.3' - 34.7' GENERAL NOTE S f PROVIDE EXTENSION RISER INISH GRADE OVER D-BOX= 34.7 '�' SLOPE @ 2% MIN. INSPECTION PORT WITH 1 WITH COVER OVER INLET& REMOVABLE WATER-TIGHT COVER OVER ACCESS BOX TO WITHIN 3"OF . UNLESS OTHERWISE NOTED, ALL SYSTEM COMPONENTS AND CONSTRUCTION FINISH GRADE OUTLET TO WITHIN 6"OF F.G. RISER TO WITHIN 6 OF FINISHED GRADE TITLE 5 OF THE STATE ENVIRONMENTAL F.G. OVER TANK EL. - 35.0'+ " ___ __ ___ ___ ___ F.G.(ONE PER OUTER ROW)__.. __ ___ __.._ ____ __._ __ ___ CODE AND ANY LAPPLICAB APPLICABLE RULES. S. @ FND. EL.= 36.0'± - -_ 5"DIA. OUTLET(S) f2. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD OF HEALTH AND THE i DESIGN ENGINEER. EXISTING 4" PROPOSED 4" 9"MIN. 36"MAX. TOP OF SAS/B.O. = 31 .73' 3. 4"SCHEDULE 40 PVC PIPE WITH WATER TIGHT JOINTS SHALL BE USED IN DISPOSAL SEWER PIPE SCH.40 PVC 36"MAX. SEWER PIPE I I SYSTEM UNLESS OTHERWISE NOTED. 6" 3" 3"DROP MAX " " PROVIDE WATERTIGHT + 4. TO PREVENT BREAKOUT, THE PROPOSED FINISHED GRADE SHALL NOT BE LESS THAN 2 DROP MIN 3 9 MIN.SLOPEA1% L =20't JOINTS (TYP.) 4 ELEVATION = 31.73' FOR A DISTANCE OF 15'AROUND THE PERIMETER OF THE SAS. UNLESS A 10" IIIIIII4" PVC IN FROM _ 1.33' 1 " 40 MIL GEOMEMBRANE LINER IS PLACE AT LEAST FIVE FEET FROM S.A.S.AND THE TOP OF -f 14" -*33.0'± SEPTIC TANK 4"PVC OUT TO (TYP.) THE LINER IS NOT LESS THAN THE BREAKOUT ELEVATION. 0.90 10.75 (TYP) CONTRACTOR TO PROVIDE LEACHING FACILITY i CLEAN SAND 5. SLOPE ALL SOLID PIPE AT 1.0% MINIMUM. SPECIFIED DROP BETWEEN INLET AND OUTLET CONTRACTOR CONTRACTOR SHALL OUTLET TEE 31 .57' MIN. 6" 31 .4' 31 .3' 30.4' 2.875'(34.5") 6. THIS SYSTEM IS NOT DESIGNED FOR A GARBAGE DISPOSAL. SHALL VERIFY SIZE 48" VERIFY CONDITION OF SIDEPORT (TYP.) 7. LOCAL BOARD OF HEALTH AND DESIGN ENGINEER TO BE NOTIFIED PRIOR TO BACK AND CONDITION OF EXISTING TEES GAS BAFFLE 5'0� COUPLER EXISTING SEPTIC AND REPLACE AS 6"CRUSHED STONE (TYP.) 1.1' 5'MIN. 11.5' (4 ROWS) FILLING WHEN SYSTEM IS NEARLY COMPLETE AND READY FOR INSPECTION. SYSTEM IS TANK NECESSARY OVER MECHANICALLY RE Q'D NOT TO BE BACK FILLED WITHOUT FIRST OBTAINING APPROVAL FROM BOARD OF HEALTH COMPACTED BASE 31.1'(6 CHAMBERS AND 1 COUPLER) AND DESIGN ENGINEER. 5 OUTLET DISTRIBUTION BOX 8. ELEVATIONS BASED ON AN APPROXIMATE M.S.L. DATUM OF 36.50' ESTABLISHED ON TO BE INSTALLED ON A LEVEL STABLE GROUND WATER ELEV= < 23.50' BIODIFFUSERS (END VIEW) THE CORNER OF THE CONCRETE BULKHEAD AS SHOWN ON PLAN. BASE. FIRST TWO FEET OF OUTLET 9. CONTRACTOR SHALL VERIFY ALL UTILITY LOCATIONS PRIOR TO CONSTRUCTION EXISTING 1,000 GALLON CONCRETE SEPTIC TANK PIPES TO BE LAID LEVEL. BIODIFFUSERS (PROFILE) THROUGH DIG-SAFE AT LEAST 72 HOURS PRIOR TO COMMENCING WORK ON SITE AT (BY INFILTRATOR SYSTEMS, INC.) 1-888-DIG-SAFE AND ANY OTHER APPLICABLE AGENCIES. REPORT ANY DISCREPANCIES SEPTIC TANK PROFILE cRoss SECTION vlEw ARC 36HC (#3616BD) BIODIFFUSERS (H-20) TO THE DESIGN ENGINEER. *CONTRACTOR TO VERIFY EXISTING ELEVATION PRIOR DISTRIBUTION BOX DETAIL NOT TO SCALE 10. ALL JOINTS WHERE PIPE ENTERS AND EXITS CONC. STRUCTURES SHALL BE MADE WATERTIGHT. TO ANY WORK& NOTIFY ENGINEER IF DIFFERENT. NOT TO SCALE NOT TO SCALE --- -- - - - 11. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH DEEDED OR ZONING SWING-TIES NOTES: •p. . '� -1 M ' • ' TEST PIT DATA TEST PIT DATA REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION FROM • - . , 1 • PERC NO. 14026 PERC NO. 14026 APPROPRIATE AUTHORITY. DESCRIPTION HC1 HC2 GC3 1.) MAGNETIC MARKING TAPE SHALL BE PLACED ALONG THE TOP EDGE OF • ' • ZONE 20 €� " � INSPECTOR: David W. Stanton, R.S. INSPECTOR: David W. Stanton, R.S. 12. ALL SEPTIC SYSTEM COMPONENTS SHALL WITHSTAND H-10 LOADING UNLESS • • • # EVALUATOR: Bradley M. Bertolo, EIT, CSE EVALUATOR: Bradley M. Bertolo, EIT CSE LOCATED UNDER PAVEMENT, DRIVES OR TRAVELED WAYS IN WHICH CASE BIODIFFUSER CORNER(1) 32.3' 39.1' 58.5' EACH SEPTIC SYSTEM COMPONENT. . , a • } THEY SHALL WITHSTAND H-20 LOADING. # • C.S.E. APPROVAL DATE: 7/29/2003 C.S.E. APPROVAL DATE: 7/29/2003 BIODIFFUSER CORNER(2) 21.3' 30.6' 52.5' 2. CONTRACTOR SHALL VERIFY SOIL CONDITIONS IN THE LOCATION OF , DATE: June 10,2013 DATE: June 10, 2013• ' ,` 13. DOUBLE WASHED CRUSHED STONE SHALL BE FREE OF ALL DIRT, DUST AND FINES. • • . � ,,/� � r � BIODIFFUSER CORNER(3) 43.2' 21.5' 28.2' THE PROPOSED LEACHING FACILITY TO ENSURE CONSISTENCY WITH TEST r/ �� ' TEST PIT#: 1 TEST PIT#: 2 14. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL LOAM, SUBSOIL AND UNSUITABLE PIT DATA SHOWN ON THIS PLAN. REPORT TO ENGINEER AND LOCAL ` • . . �, �,�,% MATERIAL IN AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF LEACHING FACILITY. BIODIFFUSER CORNER(4) 49.6' 32.5' 38.3' BOARD OF HEALTH IF SOILS ARE NOT CONSISTENT WITH TEST PIT DATA. ELEV TOP= 34.0' ELEV TOP= 34.0' '; -, , ' � ;• �• 1 �`, REPLACE ALL UNSUITABLE MATERIAL WITH CLEAN COARSE SAND FREE FROM CLAY, µ l` • Q • ' `�. �, ELEV WATER- <23.5' ELEV WATER= <23.5' FINES OR OTHER UNSUITABLE MATERIAL IN ACCORDANCE WITH 310 CMR 15.255(3). a. - 3.) ENTIRE PROPERTY NOT LOCATED WITHIN DEP APPROVED ZONE 11. PERC RATE <2 min./inch PERC RATE• • 15. CONTRACTOR SHALL NOTIFY DESIGN ENGINEER OF ANY DISCREPANCIES FOUND IN �,;� •' ♦ ,I' • ,� . _ _ • • • - SITE CONDITIONS FROM THOSE SHOWN PRIOR TO CONTINUATION OF WORK. ' t; .• * • + * ' `s DEPTH OF PERC= 30 -48 DEPTH OF PERC = 16. PROPOSED PROJECT IS LOCATED WITHIN: • a ��• • �• r.20 • ' • ' , TEXTURAL CLASS: 1 TEXTURAL CLASS: 1 ASSESSOR'S MAP 140 PARCEL 10 •�!• �,,�i ��•w +.•••'M ;« • , • • • _ OWNER OF RECORD: CLAUDIA I. MAHONEY rr " �� `#s ' ••*� `� - , '• 0" 34.0' 0" 34.0' ADDRESS: 169 SCUDDER ROAD • : li ;, \ • • + . ,H OSTERVILLE, MA 02655 • 40 Loamy Sand Loamy Sand I 1 • 10, r • • •• • • r 11 • r� p` 10YR 3/2 A 10YR 3/2 • 11 * • 0 • ; • . 10" 33.17' 10" 33.17' '���J • 4 (I • • • FEMA FLOOD ZONE C i f `, .* �. r • g Loamy Sand g Loamy Sand t '' ; j�j °, j• • LOCUS # 10YR 5/6 10YR 5/6 COMMUNITY PANEL# 250001 0016 D MAP 140 EXISTING r'' � ;�► -�""`�,� ,,% ,- _ t • 30" .E 31.5' 30 31.5' 17. DEED REFERENCE: BOOK 2096, PAGE 323 1000 GALLON LOT 11 g M Neck ' .. •• Perc - 18. PLAN REFERENCE: PLAN BOOK 46, PAGE 11 SEPTIC TANK Comer Bulkhead �Y�.,�;f �_ y� 6 a 48" 30.0' Elev. =36.5' e 4s' ._ _: ` _ 19. ALL DISTURBED AREAS SHALL BE RESTORED TO ORIGINAL CONDITION. EXISTING LEACHING PIT TO BE S PUMPED, FILLED WITH CLEAN Approx. M.S.L. 20. PROPERTY LINE INFORMATION IS ONLY APPROXIMATE. THIS PLAN IS TO BE USED ONLY SAND AND ABANDONED 1t t� - $E; ? f •• Medium Sand Medium Sand C-11 2.5Y 6/4 C-1 2.5Y 6/4 FOR SEPTIC SYSTEM UPGRADE. JC ENGINEERING WILL NOT ASSlSME AN`<. LIABILITY FOR USES OF THIS PLAN OTHER THAN ITS INTENDED PURPOSE. PROPOSED S85°2210"W 'I II k' ' �`t-,. ;. to • ,�, � C, `; DISTRIBUTION BOX -MAP 140 �rn cy 175.81 _ _ --_. LOT 3 ` Im 82" 27.17' 82" 27.17' _10LOCUS PLAN _ -2 36� n C 2 F-M Sand C F-M Sand I p 2.5Y 6/3 2.5Y 6/3 i �'' SCALE: 1"= 1000, I N 126" 23.5' 126" 23.5' PROPOSED TOTAL 24 ARC 36HC LP #169 m (#3616BD) H-20 BIODIFFUSERS AND 4 MAP 140 ' Z+ a No Mottling, Standing or Weeping Observed No Mottling, Standing or Weeping Observed SIDEPORT COUPLERS IN A FIELD \ w EXISTING ' L CONFIGURATION LOT10 -�°" 3-BEDROOM i o w DESIGN DATA TEST PIT DATA TEST PIT DATA LEGEND 18,294 S.F.t / L \ HC 1 DWELLING \ I o A PERC NO. 14026 PERC NO. 14026 co 2 TOF=36.5± ..W- � � tT1 INSPECTOR: David W. Stanton, R.S. INSPECTOR: David W. Stanton, R.S. 50x0 EXISTING SPOT GRADE 1 O = _ W o 70 \ O TOFF W o I EVALUATOR: Bradley M. Bertolo, EIT, CSE EVALUATOR: Bradley M. Bertolo, EIT, CSE 20.0' 36.5 � o O I O � NUMBER OF BEDROOMS(ACTUAL) 3 50 -- - - EXISTING CONTOUR N w I' 36 0 0 : 0 NUMBER OF BEDROOMS(DESIGN) 4 C.S.E.APPROVAL DATE: 7/29/2003 C.S.E. APPROVAL DATE: 7/29/2003 \ / June 10, 2013 June 10, 2013 50 PROPOSED CONTOUR o w \ �' 20" � \ rn � - �Oiyi m 0 DESIGN FLOW 110 GAUDAY/BEDROOM DATE: DATE: � >? 11.5' �'' 0 CRAWL w\ TOTAL DESIGN FLOW 440 GAUDAY TEST PIT#: 3 TEST PIT#: 4 ❑/H/w EXISTING OVERHEAD UTILITIES w il. SPACE rn A - �'N�k, DESIGN FLOW X 200 % = 880 GAUDAY ELEV TOP= 34.3' ELEV TOP= 34.3' W w------ EXISTING WATER LINE TP 4 18 '!�_ P O� I <24.3 ELEV WATER= � m M 34x3 HC 2 � yew I USE EXISTING 1,000 GALLON SEPTIC TANK ELEV WATER= <24.3' rn TP 3 (' (3) w STONE TEST PIT LOCATION Uj < 34x3 �` DRIVEWAY O� PERC RATE_ <2 min./inch PERC RATE _ U 1 3T4P O 11.5' GARAGE - H�w �.. v/N INSTALL (24) ARC 36HC (#3616BD) BIODIFFUSERS DEPTH OF PERC = 36"-54" DEPTH OF PERC= LP EXISTING LEACHING PIT TP 1 (4) - 'w AND (4) SIDEPORT COUPLERS 34x0 \ `''- �- SYSTEM CAPACITY TEXTURAL CLASS: 1 TEXTURAL CLASS: 1 O O EXISTING 1,000 GALLON SEPTIC TANK GC 3 (TOTAL L.F.OF BIOS)(4.8 SF/LF)(0.74 GPD/SQ.FT.)=GPD PROPOSED 4"SOLID a, " �� 'tom s LID SCHEDULE 40 PVC PIPE � rn 670' (124.4)(4.8 SF/LF)(0.74 GAUSQ.FT.)=441,9 GAL. LEACHING/DAY 0" 34.3' 0" 34.3' 17 Loamy Sand Loamy Sand PROPOSED DISTRIBUTION BOX a S82°52'10"W TOTALS: A 10YR 3/2 A 10YR 3/2 8" 33.63' g" 33.63' � PROPOSED ARC 36HC(#36166D)BIODIFFUSER(H-20) TOTAL NUMBER OF BIODIFFUSERS: 24 Loamy Sand Loamy Sand MAP 140 PROPOSED INSPECTION PORT WITH TOTAL NUMBER OF COUPLERS: 4 B 10YR 5/6 B 10YR 5/6 LOT 4 ACCESS BOX TO GRADE (TYP OF 2) TOTAL LEACHING AREA: 597.1 TOTAL LEACHING CAPACITY: 441.9 36" ;• 31.3' 36" 31.3' 1 1 6-21-13 MCP JLC ADDED RESERVE AREA Perc - REV. DATE BY APP'D. DESCRIPTION 54" 29.8' - - MAP 140 NOTE: PROPOSED SEPTIC SYSTEM UPGRADE LOT 189 EFFECTIVE LEACHING AREA OF 4.80 SF/LF OBTAINED FROM THE Medium Sand Medium Sand PREPARED FOR: DEPARTMENT OF ENVIRONMENTAL PROTECTION APPROVAL LETTER C-1 2.5Y 6/4 C-1 2.5Y 6/4 CAPEWIDE ENTERPRISES "MODIFIED APPROVAL FOR GENERAL USE" ISSUED TO INFILTRATOR SYSTEMS, INC., DATE OF ISSUANCE OCTOBER 3, 2003 (LAST MODIFIED MARCH 14,2012). TRANSMITTAL NUMBER=X235253. LOCATED AT M" 27.3' f9" 27.3' 169 SCUDDER ROAD C_2 F-M Sand C-2 F-M Sand OSTERVILLE, MA 2.5Y 6/3 2.5Y 6/3 SCALE: 1 INCH = 20 FT. DATE: JUNE 13, 2013 108" 25.3' 108" 25.3' C-3 M-C Sand C-3 M-C Sand �jF 0 10 20 ao so FEET iy� �`N� `''Ss 2.5Y 6/3 2.5Y 6/3 - 120" 24.3' 120" 24.3' "'; JOHN L. ` a PREPARED BY: CHU ���LJR. <�'� JC ENGINEERING, INC. No Mottling, Standing or Weeping Observed No Mottling, Standing or Weeping Observed �� 41 07 2854 CRANBERRY HIGHWAY EAST WAREHAM, MA 02538 SITE PLAN 508.273.0377 SCALE: 1"=20' Drawn By: BMB Designed By:BMB I Checked By:JLC 1 JOB No. 2475