HomeMy WebLinkAbout0206 SCUDDER ROAD - Health 206 Scudder Road
Osterville
` A'= 140 037 F i
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
s 206 Scudder Rd.
Property Address
Robert Shields
Owner Owner's Name
information is required for Osterville Ma. 02655 2/25/2010
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms the
computer,
r,use 1. Inspector:
only the tab key < �/v
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
r� P.O.Box 763
Company Address
Centerville Ma. 02632
m City/Town State Zip Code
(508)428-4028 S14454
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:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
S4 ti 2/25/2010
Insprector's—Slgdatur Date
The system inspector shall submit a copy of this inspection report to the Approving AutF4ority�&ard
of Health or DEP)within 30 days of completing this inspection. If the sys4M. rs a sharJiSsyst�or
has a design flow of 10,000 gpd or greater, the inspector and the system ow. er shall siubmit- e
report to the appropriate regional office of the DEP. The original should be s'nt to the`sjrsterM�wner
and copies sent to the buyer, if applicable, and the approving authority.
zir
""This report only describes conditions at the time of inspection and un r the conditio of use
at that time.This inspection does not address how the system will pe orm in ta.fut&' under
the same or different conditions of use.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Dis osal stem•Page 1 of 17
Y 9
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 206 Scudder Rd.
Property Address
Robert Shields
Owner Owner's Name
information is required for Osterville Ma. 02655 2/25/2010
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:
The septic system is in proper working order at the present time. .
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
I
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
206 Scudder Rd.
Property Address
Robert Shields
Owner Owner's Name
information is required for Osterville Ma. 02655 2/25/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box.due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
Y 4 P P 9
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
a v
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'GSM 206 Scudder Rd.
Property Address
Robert Shields
Owner Owner's Name
information is required for Osterville Ma. 02655 2/25/2010
every page. City/Town State Zip Code Date of Inspection
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.
❑ 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:
I
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® 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 1/2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
206 Scudder Rd.
Property Address
Robert Shields
Owner Owner's Name
information is required for Osterville Ma. 02655 2/25/2010
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 surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
L
� r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
206 Scudder Rd.
Property Address
Robert Shields
Owner Owner's Name
information is required for Osterville Ma. 02655 2/25/2010
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:.
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 206 Scudder Rd.
Property Address
Robert Shields
Owner Owner's Name
information is required for Osterville Ma. 02655 2/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1500 gallon tank,D-Box and 5-Infiltrators.
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2008:98,000
g ( y g (gpd)): 2009:54,000
Detail:
2008:268 gpd. 2009:147 gpd.
Sump pump? ❑ Yes ® No
Last date of occupancy: 2/25/2010
Date
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
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 206 Scudder Rd.
Property Address
Robert Shields
Owner Owner's Name
information is required for Osterville Ma. 02655 2/25/2010
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:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 206 Scudder Rd.
Property Address
Robert Shields
Owner Owner's Name
information is required for Osterville Ma. 02655 2/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
2006
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18"tee"
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 20+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
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
Dimensions: 1500 gallon
Sludge depth:
2"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 206 Scudder Rd.
Property Address
Robert Shields
Owner Owner's Name
information is required for Osterville Ma. 02655 2/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness
2"
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
12"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
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
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 206 Scudder Rd.
Property Address
Robert Shields
Owner Owner's Name
information is required for Osterville Ma. 02655 2/25/2010
every page. City/Town State Zip Code Date of Inspection
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.):
t
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 206 Scudder Rd.
Property Address
Robert Shields
Owner Owner's Name
information is required for Osteryille Ma. 02655 2/25/2010
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):
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System SAS locate on site Ian excavation not required):
p Y ( )( P
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 206 Scudder Rd.
Property Address
Robert Shields
Owner Owner's Name
information is required for Osterville Ma. 02655 2/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 5-HC Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
206 Scudder Rd.
Property Address
Robert Shields
Owner Owner's Name
information is required for Osterville Ma. 02655 2/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Map Page 1 of 2
Town of Barnstable Geographic Information System
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
206 Scudder Rd.
Property Address
Robert Shields
Owner Owner's Name
information is required for Osterville Ma. 02655 2/25/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of Leaching 20'
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: 2006
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
AS-Built
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
206 Scudder Rd.
Property Address
Robert Shields
Owner Owner's Name
information is required for Osterville Ma. 02655 2/25/2010
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
TOWN OF BAR""NSSTABLE
,LOCATION o� SC,VcQ0 I��v SEWAGE#. 'D 0
VILLAGE_ SJ�I`�g ASSESSOR' AP&PARCEL �.
INSTALLERS NAME&PHONE NOr
SEPTIC.TANK CAPACITY Z 5 v
LEACHING FACILITY:(type) , c P" (size) `®( /
NO.OF BEDROOMS
OWNER <
PERMIT DATE:�Q"�"� (0 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
a 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
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No. (/d p C 'Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC N,EALTH DIVISION - TOWN OF BARNSTABLE, MASS=ACKUSETTS Yes
application for �hgpo al �&pgtem Con.5truction Permit
F Application for a Permit to Construct( ) Repair( ) Upgrade(Y Abandon( ) Complete System ❑Individual Components
Locati ddresor Lot n i O(r�C (� O is Name,Address,and Tel.No.
Assessor's ap/Pazcel
I is Na -7 e,Address,and Tel.No. G �l �� D ig r`s me,AAd'gess and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures R
Design Flow(min.required) J gpd Design flow provided p gpd
Plan Date Number of sheets I Revision Date
Title
Size of Septic Tank I ►Wv• 50D wj=== Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by . Bo rd of He
igned Date
Application Approv 'by Date
Application Disapproved by: Date
for the following reasons
II__ i
Permit No. t�6 �1�' Date Issued
D. r P aIL1' sFee / O
i
THE COMMONWEALTH OF MASSA H ETT
Entered in computer:
� . C US S
PUBLIC--HEALTH DIVISION - T6WN OF BARNSTABLE, MASSACHUSETTS Yes
3pprication for �Bigozal �§pztem Con,5truction Permit
Application for a-Permit to Construct O Repair O Upgrade Y Abandon( �Gomplete System ❑Individual Components
r -
oo' � ; O� ame,Address,and Tel.No.
Lac" Lot No. rJ � e ��
Assessor's'Map/Parcel No i 3-1
- 1 {
Installer's Name,Address,and Tel.No.
� � �-" D�g�r's l�me,Address and Tel.No. i
P,0' '�A-7 4�1 (&1101 E RZ Mbu*,
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
E, Other Type of Building No.of Persons Showers( ) Cafeteria( )
z Other Fixtures
Design Flow(min.required) 30 gpd Design flow provided 33 �• $ gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank-0&4)• 000 29A,-- Type of S.A.S. %j (W. a
Description of Soil,`n
w !101
Ir Nature of Repairs or Alterations(Answer when applicable)
D I
Date last inspected:
:u
Agreement:
=' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisi ns of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued bythi's Board of HealthZJ5:::.
y s5(
Signed 1S li/.17' Date 6 6
Application Approved by Date
Application Disapproved by: Date
for the following reasons
.. -
Permit No. Q & 'G� ky Date Issued /l
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY,that the',On-site.Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded X
)
Abandon)d f� b '�
at �(� Yv 1 'f" 17/ - Q I I has been constructed in accordance
- d _ / .
with the prbuisi�opn�s of and the for D�isp�os/a/I-�S�tem Construction Permit No. C3 �� -- ( dated
Installer t ,�1l.Y�ililr lr'� (���✓t.N/ Designer
#bedrooms Approved design flow v gpd
The issuan e of thKrit,
mit shall not be construed as a guarantee that the system ill fund a's<designed.
Dat 7 / i�Inspector ��
No.r"7k'ItJ n 'j)-� Feed
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
=i,5po$al 6p!gtem Congtruction Permit
Permission is hereby granted to Construct ( ) Repair.( ) Upgrade ( t ) Abandon ( )
System located at 2D b °,A ,V
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provid d: Cons ction must be completed within three years of the date of pe it.
Date Approved by
f
Town of Barnstable
�tHE rqi�� Regulatory Services
Thomas F. Geiler,Director
* BARIVMBM +
9� 1639. `0� Public Health Division
Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 8-24-06
Designer: Shay Environmental Services, Inc. Installer: 'Robert Septic Services.
Address: P.O. Box 627 East Falmouth Address: 5 Trenton Street
MA 02536 Yarmouth, MA
On 8-17-06 Robert Septic Service was issued a permit to install a
(date) (installer)
septic system at 206 Scudder Avenue, Hyannis, MA based on a design drawn by
(address)
Shay Environmental Services, Inc. dated 6/16/06
(designer)
_ XX_ I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
Y
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.
�Vj H OF 4f,180
�o CARMENE.
cyN
(I ller' S' nature) SHAY
No. 1181
.p p
TEa'
SqN/TAR\N
-(Designer's Signature) (Affix Des-17VROMamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
5
1 1 I
i 9/16/03
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems. Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
�2.M I, 6 � .-r�� herebyat certify that engineered plan signed by me
dated 6 concerning the property located at
- ` �S� ��•tmeets. all of the
following criteria:
�. :. This failed system is connected to a residential dwelling only,..There.are no.commercial or
business uses.associated with the.dwelling.
The'soil is classified as.CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or may conduct deep
test holes and percolation tests.at the site without a health agent present.
• There is no.increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The.bottom of the proposed leaching facility will be located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the.
Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) Z> ,0-6
B) G.W. Elevation 15 +adjustment for high G.W. 96
DIFFERENCE BETWEEN A and B Z Z
SIGNED :_. ATE:
NOTICE
Based upon the above information;a repair permit will be issued for bedrooms
maximum.. No additional bedrooms are authorized in the future without engineered septic system
plans.
Inn
eT►iP
{
SECTION A -A ALL ounET PACES M M 1HE ,/ l i \�
10' min. from 'N ALL PIPES ARE TO BE 4' SCHEDULE 40 P.V.C.D oars PROFILE DIEW OF ADDITION TO LEACHING SYSTEM SET LEVEL FOR AT� 'rBE COVER ,o �o°� •
Existing Foundation �house to septic tank coomrs must be I: 6 r, of 1MRdmd gross 3• oft - t Wm*md Peaeton 3-r oulm
T.O.F. dev - 100.00 :t 1n 6 in f nWwd grads /2' r KNOCKOUTS
' dads oar Septic Tonle- g600 /-Geode over D-Box-8&00 ,---moods°r°r SAS->�04� 1,C to 1 1/2 ' Wadmd Crushed Stone
S 0.02 3 HOLE Tap OF Systern- Elev .%7s 4'PVC ED AWD)I BE wrim PORT TO BE
INSTALLED AND TO 6E M11w11 6'OF GRADE u \\
F771
C 10• SRO 01 or greotar (H-10)OW. BOX 3'Mmdrrerm Char 0"EMeelM Dp1A e + 1iep sfi •
1-757
EDXMW.PM NEW 1,500 GA S• Ot0' foot „ L" { r a1
�+ra,N�►, It SEPTIC TANK 20' PLAN SECTION CROSS-SECTION �� u
H-10 `� N o 's� 0 083' (10 inches) 5 Units a 625' = 30'
d
ooNRx1ENE F,"`raulNw • " 3' 3' 3 HOLE H-10 DISTRIBUTION BOX t f,
31.25 �� < t
SYSTEM PROFILE o $ > 3.5' 3.5' 37.25' NOT TD SCALE 2afaneMitItCgwiy zoossliwtiEo ', ? 1
Not to Scab 3 Effective Length
c c o 0' o SOIL ABSORPTION SYSTEM (SAS)
- EffecVve VkM o GENERAL NOTES
6 r,.of 3/4--1 1/r o .s INFILTATRUR HIGH CAPACITY (H-20 LOADING)/ GEORGE O'BRIEN
NOTE: ALL COMPONENTS MUST HAVE RISERS To WITHIN 6• BELOW GRADE compacted.ta•. 0 1. Contractor is responsible for Digd u notification, Verification of Utilities
WBottom of Test Hob 1 Gov.-67.00 °' (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes.
doundwatar Observed - NONE OBSERVED 2. The septic tank on j distn ution box shall be set
NOTE: OYERALL HEIGHT OF INFILTRATOR IS 18' /EFFECTIVE HEIGHT IS 10'
level on 6" of 3/4 -1 1 2 stone.
3. Backfill should be clean sand or gravel with no
stones over 3" in size.
4. This system is subject to inspection during installation
PERCOLATION TEST by Carmen E. Shay - Environmental Services, Inc.
5. The contractor shall install this system in accordance
Date of Percolation Test: JUNE 1. 2006 with Title V of the Massachusetts state code, the approved plan
Test Performed By. CARMEN E. SHAY. R.S., C.S.E. and Local Regulations.
Results Witnessed By. WAIVER (Per Barnstable B.O.H.) 6. If, during installation the contractor encounters any
EXCAVATOR: Shay Env. Svcs. soil conditions or site conditions that are different
Percolation Rate: Less Than 2 MPI ® 36" from those shown on the soil log or in our design
installation must halt dt immediate notification be
Test Hole Test Hole
made to Carmen E. Shay - Environmental Services, Inc.
No. 1 No. 2 7. No vehicle or heavy machinery shall drive over the
DEPTH SOILS ELEV. DEPTH SOILS ELEy septic system unless noted as H-20 septic components.
0 98.00 0 98.00 TEST HOLE #2 105.00, Failed 8. Install Tuf-rite gas baffles or equals on all outlet tee ends.
ELEV.= 98.00 Cesspool
Sandy Loom Sandy Loom 10 6' TEST HOLE #1 9. All Distribution Lines shall be 4' diameter Schedule 40 NSF PVC pipes.
r"I Failed 7-25' ELEV.= 96 0 10. All solid piping, tees dt fittings shall be 4" diameter
10 YR 3/2 10 VR 3/2 L Leach Pit
ii•-`='t'.'L� .«. s--.3.;�� � Schedule 40 NSF PVC pipes with water tight joints.
01-6' M 97.50 o'-6- 1 Ae 97.50 O
,,, ' • • • • i 11. Municipal Water is Connected to ALL OF The Residence and Abutting
Sandy L an`y _� �`•'`;� -~ =`` T'%� Properties Within 150 Feet.
to YR 5/6 10 YR s/b ,_____-- '------- 20.6'
THE PROPERTY LINES ARE APPROXIMATE AND
B, s5 00 6•_ M. B, 95.00 � `� COMPILED FROM THE SURVEY PLAN GENERATED BY
Medium/Coarse Medkim Coarse
Sand $Old
0 1 ,� ' �` ` APINWELL do LINCOLN ASSOC.
�� ENTITLED "PLAN OF LOTS IN OSTERVILLE. MA
23 Y 7/4 2S Y 7/4 i� LOB CECK �\ DATED JULY 1. 1926, PLAN BOOK 45 ,PAGE 11
36'- 132 G 87.00 38'- 132 C,
-00 87
` AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
V` IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
THE SEPTIC SYSTEM INSTALLATION.
i EXISTING CESSPOOLS TO BE PUMPED OUT AND REMOVED
� L
I
L NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
i p #206 i FROM THE EXISTING CESSPOOLS TO BE DISPOSED
iCV
i EXISTl7;'G i OF AS PER BOARD OF HEALTH SPECIFICATIONS.
�. 3 B:;•EPC fin! I �►
Perc 1 HOUSE'' i w THERE ARE NO WETLANDS ARE PRESENT WiTHtN 200' OF THE PROPERTY
Depth to Perc: 36' to 5e PROJECT BENCH MARK
Perc Rate= 2 MPI TOP OF FOUNDATION I ASSESSORS MAP 140 PARCEL 37
Groundwater Not Observed ELEV. = 100.00 (Assumed) LEGEND
No Observed ESHWT
ADJUSTED H2O Elev. = None
i DENOTES PROPOSED
3-2e DIML ACCESS MANHOLES 1 04X 1 SPOT GRADE
LOL'
#7 x 104.46
; DENOTES EXISTING
� i
�:. •�.�-•:��- --,=:;�..:_�.:;. :� I \ ° SPOT GRADE
�x.soo s Pact '
i
PL PROPERTY LINE
DRIVE EXIS
WAY ` � `
` 96 PROPOSED CONTOUR
.,LET _./ �_/ �._/ < THE ACCESS
DISTRIBUTION BOx�ANDF THE SEPTIC T LEACHING COMPONENT i - -----97 EXISTING CONTOUR
z-ter:-ter T �._,,;- = SHALL BE RAISED TO NAIHIN 6' OF L
i,.;._s `:: + FINISHED GRADE - DEEP TEST HOLE &
STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-711E GAS BAFFLES OR EQUALS
PLAN VIEW ON ALL OUTLET TEE ENDS -
� PERCOLATION TEST LOCATION
3-2a REMOVABLE cotes� ROAD OD 6 FOOT STOCKADE FENCE
min.desaroe �'CIL! -• V ��
INLET- s-mhT r min kola to osu.t .. - '� , "'� (40 FOOT RIGHTOUTLET
OF WAY)
wavr.. . T
T� ,<
P
s-r E - r-ar mtn 5-r
LOT P LAN
OF PROPOSED SEPTIC SYSTEM UPGRADE
~ - s�. - PREPARED FOR
CROSS SECTION END-SECTION MS. ALI C E SULLIVAN
TYPICAL (H-10 LOADING) 1500 GALLON SEPTIC TANK #206 SCU AT
ROAD
NOT TO SCALE
Bedroom OSTERVI LLE, MA
Design Calculations Kitchen Bath Bath OF
Number of Bedrooms: 3 Bedroom EXISTING /Dining N q - REPARED BY:
Garbage Grinder Na o= aR G CARMEN E. SHAY
Leaching Capacity Required: 330 Gal./Day (MIN. PER TITLE V) - � ' E.
Septic Tank : - 2 x 330 Gal./Day = 660 USE NEW 1,500 GAL Septic Tank. u) ENVIRONMENTAL SERVICES, INC.
SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch Bedroom Bedroom O,
Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. = 273.8 gallons Liwng a P.O. BOX 627
Sidewall Area: 0.74 gd./sq. ft. x 78 sq. ft. = 58 gallons 0 20 40 50 Room
Providing: = 331.8E gallons I S'4N TAR�P� EAST FALMOUTH, MA 02536
Use: (s) INFILTRATOR HIGH CAPACITY H-20 UNITS, � � TEL/FAX 508-539-7966
HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH. 3 OR HOUSE FLOOR SCHEMATIC '
TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE SCALE: 1 =20 DRAWN BY: CES DATE: JUNE 5, 2006
ON THE ENDS. NO STONE UNDER. SCALE: 1"=20' PROJECT#SD929 FILENAME: SD929PP.DWG SHEET 1 OF 1