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0215 SCUDDER ROAD - Health
-1 Scudder Road • OsterviIle P ,. 140006 a > ^ " ° r o s , ° a v _ No. ✓�� r FEE COMMONWEALTH OF MASSAC14USETTS V Board of Health, MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) AComplete System ❑Individual Components Location 2-1 Owner's Name S. Map/Parcel# , Address (Q 64 C '�1�a Lot# i Telephone# Installer's Name zope -.� Designer's Name �' Address Address �)-eo Telephone# ®() Telephone# M Type of Building Lot SizeI Y`IZ) sq.ft. Dwelling-No.of Bedrooms (�npRw Garbage grinder ((� Other-Type of Building ``tJ��C�i C, c� No.off persons�_Showers ( Cafeteria (Y< Other Fixtures �x �"y�j �i �P C il�Q�1 VCt1 �Q�l tr �l`yY Design Flow (min.required) . )2jQ gpd Calculated design flow U Design flow provided gpd Plan: Date Number of sheets 1 [{ Revision Date el— Title , Gac \ Description of Soil(s) Soil Evaluator Form No. �— Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS ��On The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agreesa of to ace system in operation until a Certificate of Compliance hasspbeen issued by the Board of Health. Signed Date -Y• ✓t i.�1' r ". � k 'f�V7`v 1a +Z'--..:,. . . `ert"t'..�r.z;"t..-T.tP ': ,t, �" t� _ . ., ... j ,- v j-�, .•...� �f''}1•• ����;.2jY-^.-y-.. r�]Lr ''''', "''�'lf f L_ T v�.�r.•=w�,gof'�''9-�"'a.:,rywt�'r"' -^-`�'F'�'�`-J:"_....•..-,�,i.1�...-,fir''-y."ti."K �/„r-•r. . j Al 0 FEE y� COMM®1� LT14 OF,�� .. USUTS f i Board of Health, �S�Cen S� N M APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair . Upgrade( ) Abandon( ) Complete System ❑Individual Components Location 21 5 'AMA Ap \Q Owner's Name V Nhlt Map/Parcel# vAo ('0 Address(¢(b4 C �k,`` (rQ1 S N Lot# Telephone# t Installer's Name �—�-�_ + t Designer's Name r-�1''G� �� ` ,r `�-�.,. t�C� Address�C�. VQ)C � �' tC.`(c�, Address >,R* e Telephone# 41?113 _ , Telephone# "Type of Building S\C�ed1 G� Lot Size 1 sq.ft. Dwelling-No:of.Bedrooms C-S a Garbage grinder (V� 1,.YOther-Type of Building CJ2,N©C. co INo.of persons 0 Showers ( !)!Cafeteria Mo-- Other Fixtures J •� Design Flow (min.required) gpd Calculated design flow Design flow provided 3 gpd Plan: Date ( Number of sheets ,,,�� �c? Revision Date /� J -Title ,• "•�m�US,2 'Sl�J` JIX `.'ac .tom' 'JI POSGA c� eA " / Description of Soil(s) --- �,. Soil Evaluatof Form No. Name of Soil Evaluator Date of Evaluation b ' +, DE �• DESCRIPTION OF REPAIRS ORALTERATIONS c i r The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees o of to place )system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date C.0ki ',�,'�._.�c"�-_.—}.:;:'z s�::� ..�,;�i.._,� ....�.-� .,..,�.;=..---�n--.•.�_ r .�.c < .,..:.� ._ a-_�..-m.s +. .. --�:-..,--,; ,-',A�. k;--"K-.-.*Y..�!+,.�re-.>�°�;w.r^s�.._�� �_ l v- No. � �� FEE COMMONWEALTH Of MASSAC14USETTS Board of Health, MA. CERTIFICATE OF cog�!ANGE_ Description of W6rkQJ ual,Component(s) ❑Complete System The un ersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( ) by: (n �0 rf i at urlthr A,,p has been installed in accordance with the provision�s.of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.g t dated 0'7 Approved D �gn Flow-330 (gpd) I ''^Installer Designer: Inspector: z 11LIA11 Date: f V The issuance of this permit shall not be construed as a guar-all a that the system will function as designed. No. � FEE COMMONWEALT14 O;qASSACIIUSETTS Board of Health, MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Re air Upgrade( ) Abandon( ) an indi-6dual sewage disposal system at / ,1A0 _ / as described in the application for Disposal System Construction Permit No. dated , Y 7 Provided: Construction shall be completed 'thin t`ee years of the date o thi pe &It local p nditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Dat Board of Health O l TOWN OF BARNSTABLE C fse''/w,J-..00ATION 1�� L ,,.// �2/ -X 1' SEWAGE #.01a9Y- �97 � 'L' = ' VILLAGE D l<R- t/i L ASSESSOR'S MAP & LOTIV49— ®® f "ANSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) s 690 Cd e (size) l Z X NO.OF BEDROOMS BUILDER OR OWNER �� PERMIT DATE: Qf '5-O y COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 13 p- C2 s' r -y .3y TOWN OF BARNSTABLE 6c LOCATION �� lL v,'7� .9 ter— SEWAGE#4-�q VILLAGE D APR- L'- ASSESSOR'S MAP& LOT D— 49® INSTALLER'S NAME&PHONE NO. P4370-1.r yJrf"Q3� SEPTIC TANK CAPACITY_ •• LEACHING FACILITY:-(type) \ f490 G,o&ev% (size) rZ X NO.OF BEDROOMS BUILDER OR OWNER �� PERMITDATE: r 5 -99 y 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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within,300 feet of leaching facility) Furnished by #4 1(,� /f Ir D-,Y �Z c 4 � . s + n - Town of Barnstable Regulatory Services ; Thomas F. Geiler, Director • BARNSfABLE, 9� M�; Public Health Division . '°rFn +A Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: F ILA CA— Designer: 4A Installer: , 01--i Address: ( (o o�`-�-' Address: ej On 6161o4 _ anwas issued a permit to install a (date) (installer) septic system at �Q I S :Sco cj&r ri?a , - �Ne based on a design drawn by (address) l�`prrn � dated I (� (designer) 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. 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. s (H OF A!!qS .. C' staller s ignature) �o� CARMEN E: SHAY N No. iibi Designer's Signature) (Affix �` A ere) 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 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprtcatton for Digogal *pgtem Congtruction 3permtt Application for a Permit to Construct( )Repair()O Upgrade( )Abandon( ) O Complete System XIndividual Components Location Address or Lot No. i4L J,S S C mW t4 /Q b ®$'r Owner's �Name,Address and Tel.No. .rap- a�'6;t Assessor'sMap/Pazcel s 0Q a S" £ - H /J- SCo Dt Zf o37' Installer's Name,Address,and Tell.No. SO F Designer's Name,Address and Tel.No. /4 �A OAA/CO 7- Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) A, &Z opt £ r,�T Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued)q this Board of Health1 d c� Signed Date D - F/ Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued .No. S�Z Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Migogar *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( k)Upgrade( )Abandon( ) ❑Complete System` individual Components Location Address or Lot No. /S' .5 C v- .�b£/e 19 D O S' Owner's/NN.,Address and Tel.No. Assessor's Ma p/Parcel S £ . s 0 24 0f,P M�£�a osT�yv - 0o � �. s b Installer's ICI e,Address,and Tel.No. Q p f d`-�Q Designer's Name,Address and Tel.No. 3 p ^4/N S 7- 1(v Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description.of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: E Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-4e,sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in`,operation until a Certifi- cate of Compliance has been issued this Board of Health. L� Signed Date d �/ Application Approved by Date Application Disapproved.for the following reasonsk; t f Permit No. Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CER IFY,that the On-site Sewage Disposal System Constructed( )Repaired( �Upgraded( ) Abando ed( )by /g K7 C0/4/VC© -1„ o A7A/A, j T" kow at Qj— S C 4 J 7— has been constructed in accordance with the pro •sions of Title 5 and the f ffDisposal System Construction Permit No. dated Installer Designer CY The issu ce of this permit shallot be,00n tau d as a guarantee that the syste �i1'1 function as desigried� Date "� , "/ ( Inspector -�! No.--—�-�'—�--------- - -----.-------------_Fee � _ 1 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ligpogal *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )Q Upgrade( )Abandon( ) System located at !J� .S t.) / p£/? IfJ 0157— and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must becompleted within three years of the date of this (� Date: �J J / Approved by ,- ` �' r R/y -C TOWN OF BARNS? BORTOLOTTI CONSTRUCTION, INC.` 765 WAKEBY ROAD,MARSTONS MILLS MA 0 -2G48 508-771-9399 508428-8926 FAX: 508428-9399 SUBSURFACE SEWAG E DIS POSAL SYSTEM INSPECTION FORM PART A CERTIFICATION. Property Address: / Date of Inspection: V /y Inspector's Name: — Or ner's Name and Address: CERTIFICATION STAT .MENT• . I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: t/ Passes Conditionally Passes` .' Needs FurtherEv2luatio B e Local Aprovurg.Autltority., - Fails Inspector's Signature: Date: 9°/ The System Inspector shall submit a copy of this inspection report,to die Approving authority within thir- ty(30)days of completing this inspection. If the system is'a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to Hhe appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. A)SYSTj;M PASSES: ; V I have not found any information which.indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. ti B)SYSTEM CONDITIONALLY PASSES; One or more,system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. Indicate yes,nor,�or not determined(Y,N,OR ND).*Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or.tank failure is imminent. The system will pass inspection if the existing sep- tic tank.is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water,level observed in the distribution box is due to broken or obs tructed i s r o duet r o a broken, O settled r P Pe ed o uneven distribution box. The stem will ass inspection ' system p if with approval of The B P� ( Board f PP o Health): 1 - r SUBSURFACE SEWAGE_DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction is removed 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 the public health,safety and the environment.. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY,AND THE " ENVIRONMENT:'- -The system has a septic tank and soil absorption system and isj With in 1.00 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm D)SYSTEM FAILS: the stem viol ates one or more of the following failure criteria as defined I have determined that system identified below. The Board of Health ' ' in 310 CIVIR 15.303. The basis for this determination is td should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool Discharge or ponding of efluent 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 clog ged SAS'or cesspool Ltgaid depth in cesspool.is less than 6 below invert or available.volume is less than 1/2 ...... :Q r . day flow. w ' Required pumping more than'4 times in the last year NO due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART A CERTIFICATION (conlhmcd) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from.a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant: threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400Feet of a'surface drinking water.supply., The system is within 200 Feetof a'tnbut'ary to a surface diinking water.supply - The system is located in a nitrogen sensitive area Interim WellheadProtection Area (IWPA)or a' mapped Zone 11 of a public water supply-well. The owner or operator of,any such system shall bdfig'the 5ysteih and facility'into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6,00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: ,Pumping information was requested of the owner,occupant,and Board of Health. ✓None of the system components have been pumped for atleast two weeks and the system has ,been receiving normal flow rates during that period. Large volumes of water have not been / introduced into the system recently or as part of this inspection. V As-built plans have been obtained and examined. Note if they are not available with NIA. _LThe facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste,flow. y The site was inspected for signs of breakout. . _ . _ All'system components,excluding the Soil Absorption System,have been located on site. _ /The septic tank„manholes were uncovered,opened,and the..interior of the septic tank was in- . 'spected for"condition'ofbafll'es`or"tees,'material-of construction,,dipiensions,depth of liquid, depth of sludge,depth of scum. ; `The size and'location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART B 1 �r d CIIECKI� S (continued) ilh information on were provided w if different from owner)� p . /The facile owner(and occupants, d the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' r PART C SYSTEM INFORMATION FLOW CONDITIONS RF4IDENTLAI: Design Flow::�galions Number of Bedrooms: 3 Number of Current Residents: Garbage Grinder:._ 2!j___. Laundry Connected To System: Seasonal Use: Water Meter Readings,if�ajTable: Last Date of Occupancy: 1,26 Type of Establishment Design Flow: - � aalions/day Grease Trap Present: (yes or no) y Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GEN ERAL.IN FORMATION ; PUMPING RECORDS and source of information: /s If es volume um loafs n tion: p System Pumped as part of i spec �._ Y Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy. . Shared System(If yes attach�jevious inspection records,if any) Other(explain): // LIA l APPROXIMATE AGE of all components,date installed(if known)and'sourced information: . .q Sewage-odors detectet when arriving at the - -4- SUBSURFACE SEWAGE UISPOSAL.SVS fEM.INSPECTION FORM PART . a GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: Material of Construction: concrete metal a FRP Other (explain) — Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage.etc.) GREASE TRAP: Depth Below Grade: Material of Construction: concrete �y metal FRP Other (explain) — — — - — Dimensions: Scut Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles„depth of liquid level in.relation to outlet invert, structural integrity;evidence of leakage eic) TIGHT OR HOLDING TANK: + Depth Below Grade: Material of Construction: concrete-metal FRP . Other(explain) Dimensions: Capacity: gallons Design Flow- gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) DISTRIBUTION BOX: lid Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.) PUMP. C,IIAMBER. .,rump is in,worlttrtg order: '• • �`` k- Comrnents: (note condition of pump chani6er,condition df Inunps;andr appurtenances,etc:) �_ I i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): ✓ (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: Leaching pits,number: 1 l�ching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: Comments: (note condition of soil,signs of hydraulic failure I vel of etc.) Q, pp pond's ,condition of vegetation, ., CESSPOOLS: Number and configuration: 'S iY _ ' Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: "-Dimensions of Cesspool: S"' x 5/ . Materials of construction: ' r—# Indication of groundwater:" Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure vel of ponding,condition of vegetation, etc. 2 PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) { -6- SUBSURFACE SEWAGE DISPOSAL:SYSTEM,INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. n '++' TO 4- V t DEPTH TO GROUNDWATER: Depth to groundwater: 9 Feet Method of Determination or Approximation: / j /h1QOm S. D? - P'. z_,:rra .`'•'ti�'�+'�a'.',a fig"+"'t'�s'iY 4"' ®.77 00y . ' DATE; 3/4./99 PROPERTY ADDRESS: 1'70 SSid7ce Valley ' Road Osterville , Mass . r 02655 On the above date, I Inspected the "ptic eystom at the eas. This aystem conalsto of the following; 8 1 . 1-1500 gallon septic tank . 2 . 1—Distribution box . / ► �® 3 . 2-1000 gallon precast leaching pits . q� //iv ka r S • Based bn my InPc-actlon, I certlly the following cor d�'tlonh, ,� 4 . This - is a Title five 'septic system. ('•78 tCod'e) j3 999 5 . The septic system is in proper working order' , *0 at the present -time . r\ 6 . Both. are dry. ( pits) " rZ 8IGKATUR!7, / • , Narna . J P, Kacomber Company'_J' P_Hacorqber. & �on"Tnc , Address ' __�en4,e�rv,�1Le �M,�,,y,;_Q2532 '► Phone: THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY , OSEPH P. MACOM-BER '& SON, INC, _ T+nks-Ct wpoolYla achllalds L • Pump+d 4 In;UII&d ' ' Town Siw4r Connections P.O. Box 66' Centervllle, MA 02632.0066 77.5.3338 M-6412 UqCOMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Govemor Commies-ioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 170 Smoke V a l l e t Road Name of Owner John R e c c o Osterville ,Mass . 02655 Address of Owner: Date of Inspection: 3/4/9 9 Name of Inspector:(Please Print) Joseph P.Macomber Jr . 1 am a DEP roved system ins pact or�ursuant to Section 15.340 of Tide 5(310 CMR 15.000) CwnpanyName: J Macomber & 5on Inc . MaangAddress: Box 66 Centerville ,Mass . 02632 Telephone Number: CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience In the proper function and maintenance of on-site sewage disposal systems. The system: L1 Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature:(j, Date: The System Inspect shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of*£vivirorimental Protection. The original should'be sent to-" system owner and copies sent to the buyer, if applicable, and the approving authority. . NOTES AND COMMENTS I f revised 9/2/98 Page Iof11 `J Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) ProportyAddress;170 Smoke Valley Road Osterville Owner: John Recco Daft of kupectkm: 3/4/9 9 INSPECTION SUMMARY: Check A, B, C, or A _ i - -� A.— SYSTEM PASSES: f ' `919 1 have not found any Information which Indicates that any of the failure conditions described in 310 CMR 1-5.303 exist. Any failure 1 criteria not evaluated are Indicated below. COMMENTS: The two l Parhi no—pi tv aro dry B. SYSTEM CONDITIONALLY PASSES: A)b One or more system components as described In the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes,no, or not determined IY,N,or ND). Describe basis of determination in all instances. If "not determined",explain why not. A,!D The septic tank is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was Installed within twenty(20)years prior to the date of the Inspection; or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiitration, or tank failure is Imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(&) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping-more than four-dmes a yeardue to broken or obstructed pipe(s). The vystem WKt-Pzss- Inspection if(with approval of the Board of Health): - broken pipe(&)are replaced obstruction is removed revised 9/2/98 Page 2of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) PropertyAderesa:170 Smoke Valley Road Osterville , Mass , Owrw: John Recco Data of I"sp.ctlon: 3/4/9 9 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: __AZjp Conditions exist which require further evaluation by the Board of Health In order to determine if the system Is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.WILLPRQIECT THE PUBLIC HEALT}iAND SAFETY AND THE 0i)a80NMENT. 110 Cesspool or privy Is within 50 feetof surface water Cesspool or privy Is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPUER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: �Q 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 soil absorption system and the SAS is within a Zone I of a public water supply well. 44)19 Yl1 The system has a septic tank and soil absorption system and the SAS Is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for collform bacteria and volatile organic compounds indicates that the well Is free from pollution from that facility and the presence of emmonla nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance _(approximation not valid).- 3) OTHER A revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropedyAddress: 170 Smoke Valley Road Osterville ,Mass . Owner: John Recco Daft of Inspection:3/4/9 9 D. SYSTEM FAILS: You must Indicate either'Yes" or"No' to each of the following: A;'b I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination Is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No / Backup of-sewage irrto4eci8tywr-"atemcomponent•duetto an overloaded orebggedS•AS-orceaspod. 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 lovel,in distr' upon box above outlet Invert due to an overloaded or clogged SAS or cesspool. Al JG '`Y i7 Liquid depth in,aeeepool is less than 6" below Invert or available volume is less than 112 day flow. Required pumping more than 4 timei in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped 11) Any portion of the Soil Absorption System,cesspool or privy Is below the high groundwater elevation. Any portion of a 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-wlthin a Zone i of a public wall.. 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for •coliform bacteria, volatile organio•compounds, ammonia nitrogen-and nitrate nitrogen. — E LARGE SYSTEM FAILS: You must Indicate either 'Yes' or"No" to each of the following: The following criteria apply to large systems In addition to the criteria above: AdThe system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes Nq, the system is within 400 feet of a surface drinking water supply the system•ia-vitWn-200 feat o#-e-uirautary4a-a-*urfaoa-dr4Aing-wator-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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page4orll ) I i SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 170 Smoke Valley Road Osterville ,Mass . Owner: John Recco Date of Inspection: 3/4/9 9 Check if the following have been done:You must Indicate either'Yes"or'No" as to each of the following: Yes No Pumping Information was provided by the owner,occupant,or Board of Health. None of the systemcompoaants ka+abaan puaN"d> GPNtJeasttwo. wowwaad,tbe'rystam hasbaeoasceiaiwywfrasal Aow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this Inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. ,k _ The facility or dwelling was Inspected for signs of sewage back-up. The system does not receive non-sanitary or Industrial waste flow. _ The site was Inspected for signs of breakout. _ All system components,e4uding the Soil Absorption Syitem, have been located on the site. _ The septic tank manholes were uncovered, opened, and the Interior of the septic tank was Inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: _ Existing Information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at Issue,approximation of distance is unacceptable) I15.302(3)(b)) _ The facility owner.(and.or—pan+s.1f difiaraoi lninrm;kt ocean ilia proper mains ,M �f SubSurface Disposal Systems. j I' revised 9/2/98 Page 5of11 J I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropenyAddress:1.70 Smoke Valley Road Osterville , Mass . Owner: John Recco Data of Inspection: 3/4/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow: Ild g.p.d./bedro m. Number of bedrooms de;igry�; Number of bedrooms(actual): Total DESIGN flow I_J fC Number of current residents: Garbage grinder(yes or no): Laundry(separate system) (yes ora):_; If yes, separate-inspection,required --. Laundry system inspected ( es or O Seasonal use(yes or no): .0 0. ,- - P A N Water meter readings,if available(last two year's usage(gpd): h Sump Pump(yes or no): Q k — l� V 1 A% Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: /�!L Design flow: A7� 9Pd ( Based on 15.203) Basis of design flow N Grease trap present:(yes or no) Industrial Waste Holding Tank present: (yes or no 117 A Non-sanitary waste discharged to the Title 5 system: (yes or no)zil Water meter readings,if available: - Last date of occupancy: OTHER:(Describe) , Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of i rmatioq: System pumped as part of insp ctio . (yes or no) If yes, volume pumped: gallons 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) AffI/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank ,(�fjdd Copy of DEP Approval Other AAWOXJMATEA E of all compone ts, date' tallediif known)-and source.of4eformation: Sewage odors detected when,arriving at the site: (yes or no)10 revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:170 Smoke Valley Road Osterville , Mass . Owner: John Recco Data of Inspection: 3/4/9 9 BUILDING SEWER: (Locate on site plan) 1/ Depth below grade: � Material of construction: cast iron Y40 PVC_other(explain) Distance from private water supply well or suction line 14'_ Diameter Comments: (condition of joints, venting,evidence of leakage,-etc.) Joints appear tight Nn Pvi rlPnre of l enk2gg , SEPTIC TANK: fi V (locate on site plan) Depth below grade:/ Material of construction:zoncrete metal_Fiberglass _Polyethylene_other(explain) If tank is Enetal,list agejg. 1s.age_confirmed by Certificate of Compliance 4V(Yes/No) Dimensions: : a UG Sludge depth: Distance from top.2fsludge to bottom of outlet tee vrbafflea — _ Scum thickness:-Z(�i Distance from top of scum to top of outlet tee or baffle:,,��1 Distance from bottom of scum to bottom� of outlet t e o baffle:_ZWa� How dimensions were determined: Comments: (recommendation for pumping;condition of inlet and outlet tees or-baffles;depth of liquid level in relation to outlet invert, structurahntegrity, evidence of leakage,etc.) (PUMP tank every 2-3 y arstTn1Pt R nut 1Pt tPPc arP in place . Liquid' Level at fhP n„tl Pt i nvrprt ; c f; fty Gag—J_A-6-h®_S_- ThP ranIr s; P.tr„rtur-ally semi!—Tank shows fta eyide-flee—e-� l-ea age . GREASE TRAP: (locate on site plan) Depth below grade: Material of construction sliconcreteNi4metal4�/Fiberglass4✓4 PolyethylenelAother(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: A4 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Grease trap is not present , revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C continued SYSTEM INFORMATION( ) Property Address: 170 Smoke Valley Road Osterville ,Mass . Ownw: John Recco Date of irupectlon:3/4/9 9 TIGHT OR HOLDING TANX:�(Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of construction:aconcrety4ametal&Flberglasstt/4Polyethylen&4 other(explain) .4) Dimensions• Capacity: gallons Design flow: gallons/day Alarm presen Alarm level: Al Alarm In working order:Yes / NoW Date of previous pumping: AN Commenu: (condition of inlet tee, condition of alarm and float switches,etc.) iQ t or holding tanks arp not prPgpnt DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet Invert: Comments: (note-if level end distribution is equal, evidenoe of solids carryover, evidence of leakage Into or out of box, etc.) — - — Distribution box has two la Prals _ No Pvir(Pnra of solids rarry nvpr No Pyi r(Pnra of 1 onkn Sp into -g 611,1t 6f t)i6 hQx . PUMP CHAMBER: .(locate on site plan) Pumps In working order:(Yes or No)J Alarms In working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) Pump er is not present revised 9/2/98 Page 8of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I� PART C SYSTEM INFORMATION(continued) PropenyAckkess: 170 Smoke Valley Road Osterville , Mass . Ownw: John Recco Dae of ivupecdon: 3/4/9 9 SOIL ABSORPTION SYSTEM(SAS).L'1W5f (locate on site plan,If possible;excavation not required,location may be approximated by non-Intrusive methods) If not located,explain: Type: leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length leaching fields,number, dime slops: overflow cesspool,number: Alternative system: Name of Technology: / Q� Comments: (note condition of soil,signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) Loamy sand to boney coarse sand - No signs of hydraulic fai 1 i,rr� n nnrli nna� o^' �8 ai-A dr-y weget;at;J on A ;;Q*:R;pI CESSPOOLS: (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: AA iriflow(cesspool must be pumped as part of Inspection) Cesspools are not present Comments: (note condition of soil, signs of hydraulic failure,.level of ponding,condition of.vegetation, etc.) Cesspools are not present PRIVY: (locate on site plan) Materjals of construction: �� Dimensions: /l�i4f Depth of solids:� i Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation;etc.) Privy is not present revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 170 Smoke Valley Road Osterville ,Mass . Owner: John Recco Dau of Inspection: 3/4/9 9 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes Into house) M" M' i v revised 9/2/98 Page 10of11 SUBSURFACE SEV,'AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 170 Smoke Valley Road Osterville ,Mass . Owner: John Recco Date of Inspection: 3/4/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater/ rFeet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record �bserved.Site(Abutting propertbservation hole, basemeot sump etc.) _IZDetermined from local conditions Checked with local Board of health Checked FEMA Maps --/./—C hecked pumping records ,l//Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevnti--n. (Must be completed) Used water contours map . Gahrety & Miller 12/16/94 Installed system. No water encountered at 13 ' revised 9/2/98 Page 11of11 f y+rrnnr.—nfrs+—.r.—arn. mr•nmrs'�rrt rnnrr.�r..�e-rwarrr�nr:-ernm mr..v f•a�rtsr.rr� , TOWN OF Barnstable WARD OF IiEALTII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION � �•••T••••T••.'..♦—�.fIT.^.�T 1Sf'tf'.i.TSITTI[TTI SRTI'.'T�'TTIliR�![1TRrTRRT.CPiT IiTTRTI'iTR'RT� I'eTItRTTTTRT[i9•TTTT7Ti'rr.•.�r•l•T'I�-1•�..� -TYPO OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 170 Smoke Valley Road Osterville ,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME John Recco- PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr . COMPANY NAME J. P.Macomber� & Sogv* Inc . COMPANY ADDRESS Box 66 Centerville , Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 790 - 1578 A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj system at this address and that the information reported is true , accurate , and complete as of the time of :inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and 'repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : Systeui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 - 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection wllicll I have con trcted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Ld. Inspector Signature r< < Date One copy of this c rt.ification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEAL7'1I. * If the inspection FAILED, the owner or.1.operator shall u d within one year of the date of the inspection , unless allowed ort required he m otherwise as provided in 3.10 CMR 15 . 306 . partd .doc :-I O CAT ION SEWAGE PERMIT NO. VILLAGE 054-M L rl I N S A L L E 'S : " N'A�M.,E.,F i ADDRESS ,,;BUILDER OR OWNER � * DATE PERMIT ISSUED D_AT'-E COMPLIANCE ISSUED _. , C,7e f I iogiq'l i.P • r L Fini $....5--QJQ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH I...........Tn own 0 F..........13arnstable .. ....... ...........................I.................................................... Appliration for Dhipoiial Works Tongtrurtion famit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: .....0.2-655.. ...................................................K7...........................I............... Location-Address or Lot 0. ................................................................ c udd e r..A:Kg.j.....Q,9 t(a 11Q....AA....26&5.... ............... Owner Address 14 A & B.Cess ice 1- 026ol .........................p.g.Qj..5jq . ..Tjem._4.gje.,...jjy.4.nni . MA --------------------------*,-""*-------- . .....g.............................. Installer Address Type of Building Size Lot____ _________ _________Sq. feet U Dwelling—No. of Bedrooms.........3................................Expansion Attic Garbage Grinder ( P4 Other—Type of Building .............................No. of persons_,_._.__..._.�'_............ Showers Cafeteria ( Other fixtures ---------- .....o.............................. .................................. ---------------------------------------------- ------------------------ Design Flow............................................gallons per person per day. Total daily flow..........................................gallons. Septic Tank—Liquid*capacity............gallons Length------_--.---- Width................ Diameter..-----......... Depth................ Disposal Trench—No. .................... Width.................... Total Length.....................Total leaching area....................sq. f t. 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. I................minutes per inch Depth of Test Pit---.--.............. Depth to ground water-----.-------.---_---. Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.--..................... . ............................................................................................................................................................. 0 Description of Soil........Sand........................................................................................................................................................... U .....................................................................................................................................................0.................................................. ..................................................................m...................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable----------installatio -----------------------�]n...of. .a .1. .. ,0.00..,gpjjqTj..jD 7.�cast stone packed leach pit (overfl ........................................................I...............Tlt.....................................................................0............................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE TU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance bee issued.issued by the b Ith. -j Sig4 . .. ... .......... J*......................................W-j.......7/ /al.......... t Application Approved By---------------- . . .... ........... 7.............. .............../;R, 81 ate ------------- Application Disapproved for the following reasons:................................................................................................................. ....................................................................................................................................................................................................... Date Permit No........... .......................................... Issued.................7/? 81..................... Date FEz.... ...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............T.ow.n..................OF..........�arnlstable .. .... .. ............................................................................... Xplifiratijau for Dispoind Works Tow3uurtivit "Pamit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: .215.5muddor..kyn.......Qatfx.yi11a...nA_....o26.55... .................................................................................................. Location-Address or Lot No. Allen Osborr 11A....02L5-5..... .............................Ig................................................................. 215-.5 1 Owner Aldress A.&.B Cesspool Service ............................................................................................... 1.?.8_3isb.o.ps..T.e=ar.L......Vimnis.,-.21A....02601..... Installer Address U Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms........3.................................Expansion Attic Garbage Grinder 04 Other—Type of Building ............................ No. of persons............4------------- Showers Cafeteria 04 Other fixtures ...................................................................................................................................................... Design Flow..:.........................................gallons per person per day. Total daily flow......................................W ......gallons. 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. f t. Z Other Distribution box ( ) - Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.--.--.............. Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.--..---............ Depth to ground water...................----. 0 Sim---------------------------------------------*-------*............*----------------------------*........**......".........*----------------------- �4 Description of Soil......................................................................................................................................................................... U ......................................................................................................................................................................................................... W .......................... ............................................................................................................................................................................ Z U Nature of Repairs or Alterations—Answer hen applicable-----installation...of--a---1.0.00ZAt11.Qn..'Pre:=Mst---- ---- -------------- ----- .. ......... ..stone...........pa...c..k...e..d.....l..e..a...c..h....pit...(.o...v..er..fl...c.w. ................................ . .. ............................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersig,ed-further agrees not to place the system in operation until a Certificate of Compliance h )b d by the-txag-tt a� e,pn isspe Ith. .. .................................. ........... Sig ........................ • f i�_ -1 D Application Approved By............... ......................... .............ZI& I----------- 1-1,001' D# Application Disapproved for the following reasons:................................................................................................................ ....................................................................................................................................................................................................... Date Perm No..........DL........................................ Issued-................7/ 7L-- Date --------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........I........Town.............OF........ .................................................. TWrtifiratr of Toutpliatta TH IS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired (X Cesspool Service, 128 Bishops Terrace, Hyannis, VA 02601 b3f------------- - -1----------------------------------------------------------------------- ArW . 215 Scudder Av e., Osterville, l!A 026-5 Il-. Allen Osborneat ........................................................................................... has ...........:................................................... been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the Y2411 application for Disposal Works Construction Permit No------- .................... ...:A.4................4........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE._.........8L/7/81................................................... Inspector....._. JO- ....................................................... ........... THE COMMONWEALTH OF MASSACHUSETTS- BOARD OF HEALTH TownOF...__.. OF....... . stable81- V4 .......................... � ..........;............................................ $ -00No...................0.. FEE........5................ Disposal Works T-FaInstrurtion 'pirrutit Permission is hereby granted....A & B Cesspool S p Cesservice ... ..................................................................................!......................................... ...........to COVN(Ud� or Repair X an Individual Sewage Disposal System at No......................e.r..AVe...,..-�s�ervi.11e,.-.YA 0.2655.._-_A1_1en..0.Sborne"I ........... .... ......... ......................... ..... ........... .. ........... ................ Street as shown on the application for Disposal Works Construction Permit No.--.8.1.'......... Djted.....7/24181b,.................... ..........................................- DATE.......................8/......./B2...................................... IWC- of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS SECTION A -A i• = 2000'1-house •NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. VENT PIPE (O Least 24 inches tall) ML ��PBOX SHALL H� B E10' min. from- Schedule 40 PVC w/Charcoal Odor Filter PROFILE VIER' OF LEACHING SYSTEMsETiEv>DISTRIBUi FOR AT LEASE 4 FT. 12 CONCRETE COVERExisting Foundation to septic tank qf� Septic tank covers must be within 6 in. of finished grade 3- 5'OUTLET *-' ::.�.� 2 f� Grade over Septic Tank - 99.00 Grade over D-Box - 99.00 a over - ELEV 99.00 {"ss 1 f/1"•-Aed C"'A•d Slows "N I/d'- 1/d'IasA•d PY..Eo,w '�; KNOCKOUTS I 5S' ounE1 1 tz' IN ET l MAIN STREET s 1 0.02 5�0.10 3 HOLE H-10 I 6' - f Y 15' NEW OR GREATER DST. BOX 3' Maximum Cover Top of SAS-EIev.=94.75 /Q S- 0.010' per toot n Ento o 1,500 GAL + / a o 0 0 0 0 0 -,es'- 4" - SCH. 40 Te 1.75' hh0 a' o SEPTIC TANK 25' o 0 0 0 o PLAN SECTION CROSS-SECTION R°Qcy N rn H-10 a g po 20' o o Effective Depth 2 Units 8 8.5' 17' S CRAWL SPACE FOUNOA d N oo.D.M. O, 't O 4' 9- 4• 6 h.of 3/4'-i 1/2" w 5 6N 3' A 1 =-3.5' rn 25' 3 HOLE H-10 DISTRIBUTION BOX Rogb SYSTEM PROFILE _ _ Effective Length LOCUS MAP SITE compacted -tone > 12' II 9 NOT TO SCALE Not to Scale c ° d Effective vlath SOIL ABSORPTION SYSTEM (SAS) NOTE: RE-ROUTE PLUMBING AS SHOWN °' 500 -'C H-20 LEACHING UNITS / WIGGINS PRECAST GENERAL NOTES ES6 In.of 3/4'-1 1/2' 0 compacted -tone m Not to Scale 1. Contractor is responsible for Digsafe notification NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE Bottom of Test Nola 1 Eiev.=67.00 and protection of all underground utilities and pipes. w Obs. Groundwater - Test Hole 1 Elev.= NONE OBSERVED 2. The septic tank anq distri ution box shall be set level on 6" of 3/4 -1 1 2" stone. 3. Backfill should be clean sand or gravel with no C� CO 1 N/F MAURICE CROCKER stones over 3" in size. 9 PERCOLATION TEST ` 1 4. This system is subject to inspection during installation 1 ` by Carmen E. Shay - Environmental Services, Inc. 1 \� 195.01' 5. The contractor shall install this system in accordance Date of Percolation Test: JULY 23, 2004 1 1 �� with Title V of the Massachusetts state code, the approved plan Test Performed By, CARMEN E. SHAY, R.S., C.S.E. 1 and Local Regulations. Results Witnessed By. WAIVER (per BARNSTABLE B.O.H.) 1 �� 6. If, during installation the contractor encounters any Excavated By. SHAY ENVIRONMENTAL SERVICES, INC. I 1 �\ soil conditions or site conditions that are different Percolation Rate: Less Than <2 MPI j \\ from those shown on the soil log or in our design installation must halt & immediate notification be Test Hole I i \ made to Carmen E. Shay - Environmental Services, Inc. No. 1 i 11 \\ 7. No vehicle or heavy machinery shall drive over the DEPTH SOILS ELEV.'. I \\ LOTS #1 1 & #12 septic system unless noted as H-20 septic components. 0 99.00 35,100 Square Feet 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends. �' i � \ - +/ Loamy i� �� NOTE: RE-ROUTE PLUMBING AS SHOWN 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes. Sand 6' i i 10. All solid piping, tees & fittings shall be 4" diameter 10 rR 3/2 °� I PROJECT BENCH MARK 1 Schedule 40 NSF PVC pipes with water tight joints. 0'-8" A, 98.25' TOP OF FOUNDATION ELEV. = 1Q0.00 (Assumed) 11. Municipal Water is Connected to The Residence and Abutting Loamy �i' Properties Within 150 Feet. Sand 10 ru 5/6 THE PROPERTY LINES ARE APPROXIMATE AND 8"- 30" 96.50' COMPILED FROM THE SURVEY PLAN GENERATED BY Medium _sand ASPINWALL & LINCOLN OF CENTERVILLE, MA 12-" 2.5 r 7/4 4 PVC ENTITLED " WIANNO ESTATES" " 30' _ G VENT I ";�� // OSTERVILLE, MA", DATED JULY 23, 1926, D-Box NEW 1500 gal. AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN ® Septic Tank IT SHOULD BE USED FOR NO PURPOSE OTHER THAN O EXISTING THE SEPTIC SYSTEM INSTALLATION. GARAGE EXISTING CESSPOOLS TO BE PUMPED DRY & I: CLean ut TEST HOLE #1 REMOVED IF FOUND TO BE NECESSARY TO INSTALL NEW SEPTIC TANK. ` ELEV = 98.50 11' �. �z ) NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE FROM THE EXISTING CESSPOOLSTO BE DISPOSED {"'----20' - OF AS PER BOARD OF' HEALTH SPECIFICATIONS. --------- LOT #10 Enclosed i NOTE: NO WETLANDS ARE PRESENT WITHIN 200 FEET OF PROPERTY. Porch eanout ASSESSORS MAP 140, PARCEL 006 Perc #1 EXISTING I n Depth to Perc: 30" to 48" Faile 3 BEDROOM __ I L E G E N D Perc Rate= 2 MPI (assumed) �? Cess 'o I I ire Groundwater Not Observed HOUSE _0, I � No Observed ESHWT #215 cLeanout ,\ DENOTES PROPOSED 104X1 SPOT GRADE ADJUSTED H2O Elev. = None �� I � Failed \` Cesspool I DENOTES EXISTING \ p x 104.46 SPOT GRADE THE ACCESSLOT #13 I 0 i COVERS FOR THE SEPTIC TANK, t! \ DISTRIBUTION BOX AND LEACHING COMPONENT \ PL PROPERTY LINE SHALL BE RAISED TO WITHIN 6' OF FINISHED GRADE. \ I - ----- 9�F, PROPOSED CONTOUR INSTALL TUF-11TE GAS BAFFLES OR EQUALS _-------- _-'----\;-----i'- ON ALL OUTLET TEE ENDS _ I - - - - -97 EXISTING CONTOUR I I DEEP TEST HOLE & 3-24" DIAM, ACCESS MANHOLES - I r ; PERCOLATION TEST LOCATION ,o �• l 6 FOOT STOCKADE FENCE `1 G= 98-'INUET � MlLET 07. � , _r T I I. PLOT PLAN 195.00' OF PROPOSED SEPTIC SYSTEM UPGRADE STEEL REINFORCED PRECAST CONCRETE ) \� PLAN VIEW ®AT PREPARED FOR 3-24' REMO COV MS . SUZANNE S H EA _ (40 FOOT RIGHT OF WAY) AT min � 4 ' ; #215 SCUDDER AVENUE 3' min. dearonee [, 4'-0' s-.r,Y�± INLET B' mfn�12' min. inlet to outlet 6'(m�in'. N -,a•mR Id IavN 14'r1e.1 OUTLET 5, -r 0 S T E R U f L L E, MA s -r E 1, ( � min. Design Calculations aeptNumber of Bedrooms: 3 Equivalent to 330 Gal./Day PREPARED BY: Garbage Grinder: No (330 gdp minimum per Title V)- - i Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) A ti "PAIEW E. SHAY Septic Tank - 2 x 330 Gal./Day = 660 USE NEW 1,500 GAL. Septic Tank. - CROSS SECTION END-SECTION SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch S A in ENVIRONMENTAL SERVICES, INC. Bottom Area: 0.74 gol/sq. ft. x 300sq. ft. = 222.00 gallons Q 20 40 50 No P.O. BOX 627 Sidewail Area: 0.74 gal./sq. ft. x 148 sq. ft. = 109.50 gallons TYPICAL 1500 GALLON SEPTIC TANK Providing: = 331.50 gallons � G1sTER�o EAST FALMOUTH, MA 02536 NOT TO SCALE Use: (2) PRECAST 500-C UNITS, HAVING A 2' EFFECTIVE DEPTH, AN1 T A R\F� TEL/FAX : 508-548-0796 (H- 1 O LOADING) TO BE USED WITH 3.5' OF WASHED STONE ON THE SIDES AND SCALE: 1 "=20' L 1 "=20' DRAWN BY: CES DATE: JULY 27, 2004 4' OF WASHED STONE ON THE ENDS. PROJECT#SD607 FILENAME: SD607PP.DWG SHEET 1 OF 1