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HomeMy WebLinkAbout0218 SCUDDER ROAD - Health 1 218 Scudder Avenue _ Osterville P A - 140 038 0 II o 1 o ° ^ No. L / `+' Fee / ✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppliLation for Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) [:]Complete System Individual Components Location Address or Lot No. A 1t 92.000EX k1D Obi' Owwn r'Nadne,Ad rreess,anq Tel.No. Assessor'sMap/Parcel (® PNIU.4I'5 P S(jbP 9P,Z Installer's Name,Address,and Tel.No. 6,0 1?—q'77v?,E T7 Designer's Name,Address,and Tel.No. CAPGW(pr. 6-WrO 94-565 N/A 153 " a-r Ok140P69 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(min.required) gpd Design flow provided gpd 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) C AA*J42y,^U9L)_6 P00 k-C Date last inspected: Agreement: i The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health Signed Date Application Approved by Date 7 Application Disapproved by Date for the following reasons Permit No. o _ J Date Issued No. 1;�o I .:. Fee 7 5 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppliCatlon for Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. ;L 1$ .�OaD��L. Rl� O.V. Owner's Name,Address,and jel.No. Assessor'sMap/Parcel 140 InsR 10 plilcwn P-1 sol*UP.4 M4 Installer's Name,Address,and Tel.No. $Og—'q77-18311 Designer's Name,Address,and Tel.No. �„ GE�(�CePJtpG b'�Zt�d��4S�'S �"�►t1 Cic.�J S"t" Na4t�D / 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil r ;�Nature of Repairs or Alterations(Answer when applicable)��}/(,�� ��� US(i a SEPT t G, wvyj1L �1{,57ti44� Zt�� - 4 Date last inspected: i Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date ^ Application Approved by - Date W / / v Application Disapproved by Date for the following reasons Permit No. ao 7 Date Issued (l7 J THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by AWW of 1C4?W at SOU:bbdW P� 6 ST has been constructed in accordance J with the provisions of Title 5 and the for Disposal System Construction Permit No. I dated 5/�q / 7 i Installer 6i40E-Q)Ib-6 t t(SZ' Designer_ #bedrooms Approved design flow gpd The issuance of this permit shall not be(connstrued as a guarantee that the system will function designed. E Date Il I t i Inspector ------------------------------------- No. ai� —l6 I . Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS r Misposal 6pstem Construction PPrmlt Permission is hereby granted to Construct( ) Repair(... J Upgrade( ): Abandon( ) System located at So—um)EX if r and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be omplet d within three years of the date of this:pe it. f Date S 7 7) Approv�ed-by r 1 � Commonwealth of Massachusetts Title 5 Official Inspection Form IS Subsurface Sewage Disposal System Form -Not for Voluntary Assessments SVer` 218 Scudder Rd. Property Address Paul Sullivan Owner Owner's Name information is required for every Osterville MA 02655 9/20/13 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:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: O v key to move your cursor-do not Robert Paolini use the return key. Name of Inspector Robert Paolini Septic Service Company Name 17 Playground Lane Company Address Yarmouthport MA 02675 City/Town State Zip Code 508 362-3555 S 14454 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: c� � Passes ❑ Conditionally Passes ❑ Fails c~r, ❑ eeds Further Evaluation by the Local Approving Authority Zz c. CO cc 9/20/13 Insp ctor's Signature Date s4 c Th ,s.. tem inspector shall submit a copy of this inspection report to the ApprovingAuthority(Board NofH lth or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. This report only describes conditions at the time of inspection and under the conditions of use P Y P at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. �A. I C� i l S t5ins•3/13 Title 5 Official Inspection WSsurface ewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Scudder Rd. Property Address Paul Sullivan Owner Owner's Name information is required for every Osterville MA 02655 9/20/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑x 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-all Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "r 218 Scudder Rd. Property Address Paul Sullivan Owner Owner's Name information is requured for every Osterville MA 02655 9/20/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "¢ 218 Scudder Rd. Property Address Paul Sullivan Owner Owner's Name information is required for every Osterville MA 02655 9/20113 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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: ** This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ElDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ M Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Scudder Rd. Property Address Paul Sullivan Owner Owner's Name information is required for every Osterville MA 02655 9/20/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑x Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ N Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z 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. ❑ 0 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•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Scudder Rd. Property Address Paul Sullivan Owner Owner's Name information is required for every Osterville MA 02655 9/20/13 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 ❑x ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ❑x Were any of the system components pumped out in the previous two weeks? ❑ ❑x Has the system received normal flows in the previous two week period? ❑ 0 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) ❑x ❑ Was the facility or dwelling inspected for signs of sewage back up? • ❑ Was the site inspected for signs of break out? ❑x ❑ 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? ❑x ❑ 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: ❑ ❑x Existing information. For example, a plan at the Board of Health. ❑ n 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): Number of bedrooms (actual: DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5in3.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,a"< 218 Scudder Rd. Property Address Paul Sullivan Owner Owner's Name information is required for every Osterville MA 02655 9/20/13 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ❑x No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑x No information in this report.) Laundry system inspected? Z Yes ❑ No Seasonal use? ❑x Yes ❑ No Water meter readings, if available last 2 ears usage d na 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) ICI 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•X13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Scudder Rd. Property Address Paul Sullivan Owner Owner's Name information is required for every Osterville MA 02655 9/20/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑x No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑x 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Scudder Rd. Property Address Paul Sullivan Owner Owner's Name information is required for every Osterville MA 02655 9/20/13 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: Were sewage odors detected when arriving at the site? ❑ Yes ❑x No Building Sewer(locate on site plan): � Depth below grade: 3' feet Material of construction: ❑ cast iron O 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 104 feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the building vents. Septic Tank(locate on site plan): Depth below grade: 2' feet Material of construction: 0 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 gl. Sludge depth: 3" t5ins•3l13 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 218 Scudder Rd. Property Address Paul Sullivan Owner owner's Name information is required for every Osterville MA 02655 9/20/13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 11" 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 2 years.Inlet 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Scudder Rd. Property Address Paul Sullivan Owner Owner's Name information is required for every Osterville MA 02655 9/20/13 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: p Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 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 218 Scudder Rd. Property Address Paul Sullivan Owner owner's Name information is required for every Cisterville MA 02655 9/20/13 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 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 level.Box has one outlet laterals.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.): "If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 5ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Scudder Rd. Property Address Paul Sullivan Owner Owner's Name rquired for is every required Osterville MA 02655 9/20/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑x leaching chambers number: 4 3050 chambers ❑ 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 soil.No signs of hydraulic failure.Leaching was dry at time of inspection. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Tithe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 218 Scudder Rd. Property Address Paul Sullivan Owner Owner's Name information is required for every Osterville MA 02655 9/20/13 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.): Privylocate on site plan): ( p ) Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Tide 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 218 Scudder Rd. Property Address Paul Sullivan Owner Owner's Name information is required for every Osterville MA 02655 9/20/13 page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately I i I I 1 0 o I 4 3r, t .. i - Q p i i i 3 i t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•?age 15 w 1? � Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Scudder Rd. Property Address Paul Sullivan Owner Owner's Name information is required for every Osterville MA 02655 9/20/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑x Check Slope Fx� Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of leaching 22' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: 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 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form (� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Scudder Rd. Property Address Paul Sullivan Owner Owner's Name information is required for every Osterville MA 02655 9/20/13 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑x Inspection Summary: A, B, C, D, or E checked FZ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑x System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate fife t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Q Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 218 Scudder Road Property Address Allison Cottrill :v Owner Owner's Name information is required for every Osterville Ma 02655 4-12-16 page. City/Town State Zip Code Date of Inspection m 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:When filling out forms A. General Information on the computer, b use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation Company Name 374 Route 130 _ Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113640 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 4-12-16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 218 Scudder Road Property Address Allison Cottrill Owner Owner's Name information is required for every Osterville Ma 02655 4-12-16 page. Cityrrown 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: y System was in working order at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Scudder Road Property Address Allison Cottrill Owner Owner's Name information is Osterville Ma 02655 4-12-16 required for every ' page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): r ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): i ❑ ' 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 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Scudder Road Property Address Allison Cottrill Owner Owner's Name information is required for every Osterville Ma 02655 4-12-16 page.e. Citylrown 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: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in,cesspool is less than 6" below invert or available volume is less than '/day flow _ t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 218 Scudder Road Property Address Allison Cottrill Owner Owner's Name information is required for every Osterville Ma 02655 4-12-16 page. Cityrrown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Scudder Road Property Address Allison Cottrill Owner Owner's Name information is required for every Osterville Ma 02655 4-12-16 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): 4 Number of bedrooms (Actual) 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 459 , t5ins•3/13 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 218 Scudder Road Property Address Allison Cottrill Owner Owner's Name information is required for every Osterville Ma 02655 4-12-16 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): See below Detail: 2014- 112,000gallons 2015-254,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Summer 2015 Commercial/Industrial Flow Conditions: Type of Establishment: NA 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•3/13 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 218 Scudder Road Property Address Allison Cottrill Owner Owner's Name information is required for every Osterville Ma 02655 4-12-16 page. City/Town State Zip Code Date of Inspection Do System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- last pump unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °w 218 Scudder Road Property Address Allison Cottrill Owner Owner's Name information is required for every Osterville Ma 02655 4-12-16 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: 2003 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1 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 Sludge depth: 4 , t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments "M 218 Scudder Road Property Address Allison Cottrill Owner Owner's Name information is required for every Osterville Ma 02655 4-12-16 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 32" Scum thickness 0 11 Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS 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.): Tank was in working order at time of inspection.with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 218 Scudder Road Property Address Allison Cottrill Owner Owner's Name information is required for every Osterville Ma 02655 4-12-16 page. CitylTown 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): 9 9 ( P P P ) ( P ) Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain).- Dimensions: Capacity: gallons Design Flow:, gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 218 Scudder Road Property Address Allison Cottrill Owner Owner's Name information is required for every Osterville Ma 02655 4-12-16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up or carry over. 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.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Scudder Road Property Address Alliison Cottrill Owner Owner's Name information is required for every Osterville Ma 02655' 4-12-16 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (4) cultec 3050s ❑ 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 soH, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Leaching was dry. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool c Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 218 Scudder Road Property Address Allison Cottrill Owner Owner's Name information is required for every Osterville Ma 02655 4-12-16 page. CitylTown 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: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts F 'Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Scudder Road Property Address Allison Cottrill Owner Owner's Name information is Osterville Ma 02655 4-12-16 required for every , page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately READI%,J7 DECK A3.191611 Y .1716" r t t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 218 Scudder Road M Property Address Allison Cottrill Owner Owner's Name information is required for every Osterville Ma 02655 4-12-16 page. CitylTown 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: No Gw 132" 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: 8-3-03Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 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 218 Scudder Road Property Address Allison Cottrill Owner Owner's Name information is required for every Osterville Ma 02655 4-12-16 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 l t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 4 TOWN`OF BARNSTABLE LOCATION � O �� R SEWAGE # VILLAGE l` ASSESSOR'S MAP &.LOT� L�t, ,SNSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) ,NO. OF BEDROOMS— BUILDERUV\racn BUILDER OR OWNER N ciL\0, PERMITDATE: 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 wetlznds exist within 300 feet of leaching facility) _ Feet Furnished by �� � e !� � . ., , . .. .� .. �. -_-`..,..�.........»..w.,..�.T.�.a=+wr+v,��gro-y�Y}+'�J�.,4�'��yi�'*a.,ci e.a d'.F+...4.. � ... �: w-«n+.�.�.rn�.«mow...�.w++u..wm+,�..........�,.-.,�.�.......,fi.......,.�.....»......»,.....�.o.+w-......,.,......«....a„�....,.4.:+w•a.�.:k1C,ii��E:�8.4 r.....'.�,:..-..':...a.. .�. :i+.:'�"", .r a�a ..- " «., f TOWN F BARNSTABLE LOCATION �`� SEWAGE # ?VO G VILLAGE ® Ut ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY L� y LEACHING FACILITY: (type) �/1,��� 5 (size) �40.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: �'�`d� COMPLIANCE DATE: . /``43 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 �� � r — � f, 0 n 7 1 � � � � � �' �� � ` �-, � �`� J —346 4 Fee �— \_ Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE, MASSACHUSETTS Zipplication for &5pogaf 6p.5tem Con0truction 3p ermit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. ner's Name,Address and Te o. .,0 ••7 �s / Assessor's Map/Parcel �� Yin e 's Name,Ad s,and TekNo. isbg 77 Q I '�j'Q D er',s Nam ,Ad an Tel. o. '7(J 1 !U o l[� -- Type of Building: Dwelling No.of Bedrooms�_ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures LtLth Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets_� Revisi Date Title Size of Septic Tank Type of S.A.S. Description of Soff —, plaq Nature of Repairs or Alters 'ons(An er when app 'cabl ) DESIGNING ENGINEER MUST SUPERVISE Date last inspected: INSTALLATION AND CERTIFY IN WRITING Agreement: THE SYSTEPA WAS INSTALLED IN STRICT The undersigned agrees to ensure the construction and maintenance of the afore described on-siteTsewageldisposal system in accordance with the provisi s of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is ed by is Board ealth. a /_s Sig Dat (� Application Approved by Date C� Application Disapproved for the following reasons Permit No.­��2 � �349k! Date Issued r - Fee_- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ' ZippYication for Migaar,*p.5tem Congtruction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon ) El Complete System ❑Individual Components Location Address or Lot No. ��r� rn' d ®'Y er's Name,Add ss and .No. .oZ Assessor's Map/Parcel v`�Te, V' �jj �JrC�� �b( / t 1 4v b�Y Ka►�.� r Iastall e,Ad ress and del.No. D si ner; ddre d T 1.No. M tj #�ann t5,,02Af Type of Building: Dwelling ` No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 40 Design Flow _ gallons per day. Calculated daily flow gallons. gyp Plan Date Number of sheets Revision Date Title Size of Septic Tank / /� �Typ of S.A.S. Description of Soil �LV W t� p'. 0y") 5� - Nature of Repairs or Alterations Answer when app 'c le r f 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 issed . this oardMlizalth.Sign _ `' " Date Application Approved by Date Application Disapproved for the following reasons Permit No. 3 --344- Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE TIF t t th -On-ske.SS�wage Disposal System Constructed( )Repaired( Upgraded( ) Abandoned( )-by �� at 2a <�(u d?,W r OQ CL 00 KrY 1 I has o n constructe in cco(qance with the pro\isi�t e b and the -rtri—sposal System Construction Permit No. dated Installer Designer The issuance of his permit shall not be construed as a guarantee that the system w'1�L lo(�Wsid. Date O 3 Inspector �/',,'� --^---,----------------------------------- No. �"-' 3 b Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migo,5ar *p.5tem Construction Permit Permission is hereby granted to Construct( Repair( )iUpgrade Abandon( ) System locatarJ J U A V I D 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 orspecial conditioCthi Provided:Cons ction�ust be completed within three years of the date pe it. Date:__ �z " 3 Approved by 'r TOWN F BARNSTABLE LOCATION `� SEWAGE# G VILLAGE ® vi I ASSESSOR'S.MAP&LOT 36 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY � LEACHING FACILITY: (ty (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: �`�`03 COMPLIANCE DATE: '2L Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by I IL fy a O ,� 0 Sep - 20-01 13 ; 52 BARNSTABLE HEALTH DEPT 5087906304 N . UL sit ;o� I . NOTICE: This Form Is To Be Used For ttie Repair Of Failed Septic Systems Only. PERCOLATION TEST A1YD SOIL EVALUATION EXEMPTION FORM C s hereby certify that the engineered pian signed by me cjetec concerning the property located at meets all of the • This failed system is connected to a residential dwelling only. There are no :orruntr,:ia! or business uses associated with the dwelling. T? e soil is ciasss ed as CLASS I and the percolation rave is less than or equal; to rt:n�tes per inch. The applicant may use histoncai data to conclude this f3c: or may :or,duc:t pre'tm,.,ar% tests at the site without a health agent present • Therc :s no increase in flow and/or change in use proposed • There are rto variances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen 141 fee: aoove the maximum adjusted groundwater table elevation. �Ad.iust the ;roun(!-wa:cr table using the Fhmptor method when applicable) Please complete the following; lop of Ground Surface Elevation (using GIS information) r; tJ.w' E!c�ar.on _ ad;uscrncnt for high G.W. _1•9 = � >'R-T.R.ENCF BETWEEN and B p SWED DATE: 3asec jrort the a-love r.for-matron, a repair permit wil! be issued for bedr^oms `+r, ,,ddsu:�nal bedrooms :ue authorized to t`te future wi°,bout envneerec 1:ept,. syste^s plans. �c_nn!r,;dci Pc1cc.tmp s r Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: �� �C11��@�" � ® c �oltQ , Lot No. Owner: COE;M Address: Contractor: ��J nt3ict�RRL� Address: sko Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. ................................I.............................................. .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: t� OAppropriate index well................................................... (�B Water-level range zone ........................................:............ °J STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... ®J •lp month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) Q determine water-level adjustment ................. ,—i ............................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) . h Figure 13.--Reproducible computation form, 15 CARMEN E. ,SHAY (508)-548-0796 ENVIRONMENTAL SERVICES, INC. P.O.Box 627,East Falmouth,MA 02536 August'7, 2003 RE: Certification of Title V Septic System Installation: Residential Property 218 Scudder Road, Osterville, MA Dear Sir or Madam: On August 6, 2003, Roger Roberts, Inc. was issued a permit to install a Title V1 Septic System at 218 Scudder Road, Osterville, MA, based on a design drawn by Shay Environmental IServices on August 5, 2003. j } i XX I Certify That The Septic System Referenced Was Installed Substantially;According to the Plan t I Certify That the Referenced Above Septic System Was Installed With Changes but in Accordance With State and Local Regulations, Revisions or As-Built Plans/Sketch will Follow. The Septic System Was Not Installed Per State and Local Regulations acid Corrective Action is Required. If you have any questions,please do not hesitate to call the undersigned at(508)-548-0796. Sincerely, CARMEN E. SHAY ENVIRONMENTAL SERVICES,INC. i En . 0. C n E. Shay, R.S., C SHAY j No. 118 President, .. �o Gf3TEa. SqN/?AWR Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection One waiter Street,Boston,Ma. 02108 John Gt ad D.E.P. Ti Septic Inspector eaticket, 6 WILLIAM F.wELD ^Governor (508) 4-68I3' ARGEO PAUL CELLUCCI fj►�►'��0 !� Lt.Governor 4[ SUBSURFACE SEWAGE DISPOSAL ASYSTEM INSPECTION F .0l� 2 4 199� Ir -CERTIFICATION OF N Property Address; 218 SCUDDER RD.OSTERVILLE MAP 140 PAR 038 44, Date of Inspection: 11/10/98 Address of Owner: A Name of Inspector: JOHN GRACI (If different) y I am a DEP approved system inspector pursuant to Section 15.340 of Title°k(3 LL 0 CIAM CRA 5 NDELL;BOX 685 MILBURY 00) Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system:, x Passes This Inspection Is based on criteria defined In Title V - Conditionally Passes code 310 CMR 16.303.My findings are ofhow the system is — Needs u ther Evaluation By the Local Approving Authority oilmmygatthany warranty of the genie iof h yinspectionlongevity does _. Fails - septic ofthe .. p system and any of Its components useful life. Inspector's Signature: Date: 11116198 s The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days'of completing this inspections. 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 Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion. of the replacement or repair,passes inspection. Indicate yes,no, 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Colhpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, of lank failure is imminent.The system will pass inspection If the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (rev1;ed 04a7197) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) t• Property Address: 218 SCUDDER RD.OSTERVILLE MAP 140 PAR 038 Owner: iMLLIAM CRANDELL;BOX 685 MILBURY MA.01521 Date of Inspection:11/10/98 4 . — Sew.acte backup or,breakout.or hiah.static Water level observed.in.the distribution box is due to a broken, or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled 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 FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: — The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. — The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 the SAS 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 that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or ' less than 5 ppm. Method usedto determine distance (approximation not valid) � ' 3)Other DI SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of.the following: l I have determined that the system violates one or more of the following failure criteria as defined 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 in facility or system component due to an 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 rinrdged cesspool: SAS is in hydraulic failure. (revised 04127)97) k SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 218 SCUDDER RD.OSTERVILLE MAP 140 PAR 68 Owner: MLLIAM CRANDELL;BOX 685 MILBURY MA.01527 Date of Inspection:1111019E D]SYSTEM FAILS (continued) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. . Liquid depth in cesspool is less than 6"below invert or available volume.is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due.to clogged or obstructed pipe(s). Numbers of times pumped 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 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 160 feet but greate(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: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and'the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes 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) The owner or operator of any such system shall bring the,system 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. n a (revised 04121197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Add re Ss: 218 SCUDDER RD.OSTERVILLE MAP 140 PAR 038 Owner: WILLIAM CRANDELL;BOX 685 MILBURY MA.01527 Date of Inspection:11110198 Check if.the following have been done:You must indicate either"Yes"or"No"as to each,of the following: _c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. x As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. _c_ — The site was inspected for signs of breakout. x . All system components,excluding the Soil Absorption System, have been located on the site. x 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. x The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x — Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is — — unacceptable)[15.302(3)(b)] (revised 04117)97) f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION Property AddreSS: 218 SCUDDER RD.OSTERVILLE MAP 140 PAR 038 Owner: tMLLIAM CRANDELL;BOX 085 MILBURY MA.01527 Date of Inspection:11f10198 FLOW CONDITIONS RESIDENTIAL: ; Design flow: 0 g.p.d./bedroom for S.A.S. Number of bedrooms: 2 Number of current residents: u Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes i Seasonal use(yes or no): No Water meter readings, if available:(last two(2)year usage(gpd): rda Sump Pump(yes or no): No Last date of occupancy: SYSTEM WAS LAST OCCUPIED 3 WEEKS AGO COMMERCIAL/INDUSTRIAL: Type of establishment: nia Design flow:0 gallons/day Grease trap present: (yes or no) No Industrial Waste Holding Tank present:(yes or no) No " u Non-sanitary waste discharged to the Title 5 system:(yes or no) Na , Water meter readings,if available: ora Last date of occupancy: nra OTHER: (Describe) Na Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: SYSTEM HAS NOT BEEN PUMPED IN THE LAST YEAR. System pumped as part of inspection:. (yes or no)No If yes,volume pumped:0 gallons Reason for pumping: Na - TYPE OF SYSTEM Septic tank/distribution box/soil absorptions system x Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other. , APPROXIMATE AGE of all components, date installed(if known)and source information: t 1960 Sewage odors detected when arriving at the site: (yes or no) No (revised 04127197) a , • 4 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION (continued) • e t. _ Property Address: 218 SCUDDER RD.OSTERVILLE MAP 140 PAR 038 Owner: INILLMM CRANDELL;BOX 685 MILBURY MA.01527 Date of Inspection:11110198 ' SEPTIC TANK:_ (locate on site plan) Depth below grade:irda Material of construction: concreate metal FRP Polyethylene_other(explain) If tank is metal, list age n1a . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: rda Sludge depth:rda Distance from top of sludge to bottom of outlet tee or baffle: rya Scum thickness:rya Distance from top of scum to lop of outlet tee or baffle:rya Distance form bottom of scum to bottom of outlet tee or baffle: rya How dimensions were determined: rda 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.) rda GREASE TRAP: (locate on site plan) Depth below grade: rda Material of construction: concrete metal FRP Polyethylene_other(explain) Dimensions: rda f. Scum thickness:rya 5 Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: rda Date of last pumping;(. , Comments: } (recommendation for pumping,condition of inlet and outlet tees or"battles, depth of liquid level in relation to outlet,invert, structural integrity, evidence of leakage, etc.) rda BUILDING SEWER: k. (Locate on srte plan) Depth below grade: a Material of construction:_cast iron_40 PVC_other(explain) y, ` Distance from private water supply well or suction line:TOWN , Diameter: nla Qmments: (conditions ofjoints,.venting,evidence of leakage, etc.) (revlaed04127197( , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 218 SCUDDER RD.OSTERVILLE MAP 140 PAR 038 Owner: IMLLIAM CRANDELL;BOX 685 MILBURY MA.01527 Date of Inspection:11110198 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: rda ' Material of construction:_concrete_metal_FRP Polyeth'ylene_other(explain) Dimensions: nfa Capacity: rda gallons Design flow: rda gallons/day Alarm level:_nfa Alarm in working order? - Yes No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nfa DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nfa Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) Na - - PUMP CHAMBER: (locate on site plan) Pumps in working order.(yes or no)No Alarms in working order(yes or no)Ye: Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) n/a h (revlaed 04f27197) " • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ` Property Address: 219 SCUDDER RD.OSTERVILLE MAP 140 PAR 038. Owner: VALLIAM CRANDELL;BOX 685 MILBURY MA.01527 Date of Inspection:11/10198 SOIL ABSORPTION SYSTEM (SAS): w (locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: rda Type: leaching pits,number: Na leaching chambers,number:NB leaching galleries,number: Na leaching trenches,number,length: Na leaching fields,number, dimensions:Na overflow cesspool, number:Na Alternate system: Na Name of Technology._Na Comments: (note condition of soil, signs of hydraulic failure,level ofponding, condition of vegetation, etc.) Na CESSPOOLS:x (locate on site plan) ` Number and configuration: ONE Depth-top of liquid to inlet invert: EMPTY;SHOWS SIGNS OF BEING3M FULL. Depth of solids layer: Na Depth of scum layer: Na Dimensions of cesspool: e'x6'H10 Materials of construction: PRECAST Indication of groundwater: Na inflow(cesspool must be pumped as part of inspection) Na Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) y ' MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALL SOUND.RECOMMEND PUMPING SYSTEM EVERYYEAR.SYSTEM WAS NOT INSPECTED UNDER NORMAL USE WHEN HOUSE WAS OCCUPIED. PRIVY: s.. (locate on site plan) Materials of construction: Na Dimensions: Na Depth of solids: Na Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) Na • _ r. a y (revised 04 D97) " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 218 SCUDDER RD.OSTERVILLE MAP 140 PAR 038 WILLIAM CRANDELL;BOX 685 MILBURY MA.01527 11110198 A SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) o. .._ 13 L WA (revmed04)27197) Pay ! of 10 - s- a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 218 SCUDDER RD.OSTERVILLE MAP 140 PAR 038 WILLIAM CRANDELL;BOX 685 MILBURY MA.01527 11110198 Depth of groundwater 12. Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS MAPS AND CHARTS (revised04127197) page 10 0[ 10 Q LO z Lox z N o Q r) N O Q N � 00 Q N U � a � 0 o OQ � Z0 000 m � rn a0 I o rn LL O Q N V Lo, O Q' STD gOAD (0a -0 - 0) O L� >_ j J 3 m GSA' Quern I I o\ Q � L � W -� X 3 A W J —1 Qr �a, DDEg � Q < � Q � w � � � Z o gpAD O � a J o U W 12 - m W z 0 0 ( U m W' U) W O 0 Q Cn ~ 1 0 O O cn m RpAD � (A z : 000 a- 0- U u � � � � ' WP or w � z O W Q 'Nw00wo Y O o c- wU ) C) W w Z Q LLI 0wNZ ~ UZF- J > > > z vY N "1 JW (n0W JQQ n w w w Q 0 0_ 0QN (nli0_ 0 � � }- H T ®® 5 o g w �o N � vo > o a ® co � � ® < Q I ) U-) c� K} ® w a i0r, a ® i uj p b� 6 Ow ��� ®®® N W Ii Z ®vvv®®a U F- ww J W UDC w H N d > FFr�i J d O W U w I Q a (� q IZ w 0 0 0 Or N C) QHH -I aO Q � . 60 CL oxxo Q- N 0'S6" W 105.00' N 03°3 FENCE , o w N _ +' J r 0 N r J U lL- it Z W f i �t 0 � <00 t) N Z 0 Z e- € m I 0_ € J i O, € a�� w O Q Ln 0. a N QM 0 i C) d I IIIIII Z Ad o w d I I I I I I I I I w d a ' n o w IIIIIIIII I ( IIIIIIIII I I I I I I I I I I I a IIIIIIIII rIIIlIlI1III00 Q � I I I 00I I I I I I I I I I I N I I I I I I r 1 1 1 1 1 1 1 1 1 1 1 I I I I I I I I I I I 6,0.9ft, q I I I I I I I I. I I I I 3 � � J-gel IIIIIIIIIII I I I I CP w >•I N eZ° WM/� N 3 A . cD cD 0 w l" o 2� I o 105,00 S .� 07°07'50 E R � •,I e OAD ERR SCUDD , In do w /wF O b a dLp -,��,T 71 p � oo III Chi,• c _ RsraA { ttt Ef r C , /�I a 1 , V-77) 3-. �if�Ad Nool e O I+ CT _ t. 2000 / SECTION A ,I A ALL twnEr PIPES FROM THE ".:01SIROUTION sox SHALL 9E .9 12 PROFILE-:VIE ilr OF LEACHING `SYSTEM AT T 1^r. rR 1 10 ern. from i SET t£vEL Far lfAs 2 ti NOTE: Ali PIPES .ARE TO BE-4 SCHEDULE'40 P.V.C, e, o septic tank r Existing Foundation thous t ep c a Not Scare f_•.. .. . . J' -< Sepik tank covers must be 3 S*OUTLET TOF,ELEV 100.00 (Assumed) KHOCKOUTs C� within B k�. at rfnisfied a. F - aver rags- a>:va-ss.00 _ T rkade over Septic Tank- ss.00 trade o•.er t>-ew�-ss.oa a or r/s ,r/i ►..r..d ra.e� MAIN R . ST EET 4 b f f �iehei f7noked 86one ss 12' w�iFr > , 2 3 4iall H 10 �+ h T f S ev— 50 S-0 o a SA -Et ,-96 .1Q :130X P ,. . _ . 70 O1S7 15 5 v77 ,, ,, 3 Moxlmum Cover': � , .. :. ., - � NEW GREATER , 1 - a 500 GA , EXIST. PIPE 1 L 4`n- .FRQN frARtDATIQI :. -:;. Q. J' a�at PLAN SECTION CRO58 S CTION c SEPTIC TAW .. (/ o II a H 30 Effective 11 ,� f` N SITE ecdve o, m Ere + o Ssdewa i R 3IE CONCRETE FULL f" 3 HOLE:� _ 10 DISTRIBUTION cox ar e N . , M o $ , 6 .o /4 > O a NOT TO SCALE-. .:,.. .'o i, .: r. 4 o -': ... -. ... :. .� -.,` '. L..�GUS MAP 11 'SYSTEM `PRQFILE ted'stane _ 4 Not to Scale 36 c 12 q ' Effetttve Length , a 9 o ; o SOIL ABSORPTION SYSTEM-CSAS w . .' CSVII AD .' ed stone > PJOTE. .::ALL COMPONENTS MUST HAVE RI�5'TO "THIN 6 BELOW GRADE compact ,. T R'13 DUNBAR GENERAL NOTES ' ... INFtLTRAI[lR MODEL.`3t)50.<H 20 LOADING)/ SUMNE r " -responsible €o i notification m 1. :Cont actor es res ens b e r,b safe na ec R EQUIVALENT) P Dig safe, . . :, 'r t tion II underground, illtles i es, and a ec of-aut and Bottom ar Test�a t oer. 88.00 1I HEIGHT 15 24 pPP .. NOTE. OVERALL HEIGHT OF INFILTRATOR 1S 3D /EFFEC VE . 2. The septic tank cln drs#nbutroi� box:.shalt be set ' level on $_ of - 4 1, 1 2 tone. n gravel h 3. Backt`ill should be clean sand or, a e with no 4 r : stones, over 3" to size. , EXISTING CESSPOOL'TO BE PUMPED & FILLED PLACE r`: 4, This, is .subject to rnspection during tns#altatron 3-24 DIAN.ACCESS MANHOLES `T N -'Environmental e ' to UN T N TO INS ALL EW SAS b Carmen hS rvlces c. _ , OR REMOVED :lF FOUND 0 BE ,NECESSARY y a E. Say , -s n ` t r h install , stem rn ecorda e ' S. The cantrac a shall 1 sta th s � a c CHA Y NOTE: 'STRIPPED OUT SOIL CONTAINING LEA TE 0 E. ANY STR E with Title V of> he Massachusetts state code, the approved Ian '. :t PP P t H` TO BEDISPOSED;.. :FROM THE �+CISTING LEACH PITS/CESSPOOLS CESSPOOLS and :.Local Regulations. ! _ OF AS PER BOARD OF HEALTH SPECIFICATIONS. _6. tf,.duntl ins tollatlon the contractor encounters an . sort co 1tlons or site conditions that are:d ff rent.. n� 1 e _1 INLET 1 those: win h sot to r n riot desl n 1 OUT from th s shown on the I g o t g INLET tnstallatron :must halt & tmmedrate ;natlficai'on be' THE AC COVERS FOR THE SEPTIC TANK ACCESS Y �, _. made to Carmen E. Shay .Environmental 5ervtces Inc. iN5TR18UTlQN 80X AND LEACHING:COMPONENT Y a WITHIN 6 . ..-• ». -». SHALL 8E RAISED TO TH OF �_ �-- . t-. .,.•�.--r•, '?. No::vehicte or heavy machine shalt tlr'rve tsvet' the FINISHED GRADE.' �Y 7 �eptrc system unless noted as H-20 peptic components.. STEEL REINFORCED PRECAST CONCRETE INSTALL TUF TITE CAS BAFFLES OR EQU ALS i' 8. Instals Tuf-Tits as baffles or equals on all outlet tee ends_ ON ALL f/uTLe`r TEE'ENDS 9 q LAN VIEW P _ , . - " II diameter .Schedule 40 NSF'.:.PVC pipes. `9. All Drstributron Lines she be 4 d t P P 3-24 REMOVABLE crncas 16. All 'solid piping, tees & fittings shall.be' 4.. diameter � LOT 4 LOT #3' 0 P P 9, 9 Schedule 40 NSF PVC :pipes with water tight;.joints. -, -.. •' 11, Munrci at Water is Connected to The'Residence and Abutting 3 min. dearanw r parr .,,: p i4 m_"-;__:_I2' ►Met to outlet d�, Properties Within:200 feet, _._... OUTLET - .. '.,. trr, , s -r 1 s _r E -r-Q'min. • g I THE PROPERTY_LINES 'ARE APPROXIMATE AND o..60% uy�rid depth COMPILED FROM..THE­SURVEY PLAN GENERATED- BY ASPINWALL & .INCOLN OF CENTERVILLE, MA -.�_ -- •• - �... _ f ENTITLED'" W1ANN0ES"CATE"S" o, _B- OSTERVILL.E,: MA , DATED JULY 23. 1926, fo-o 1 T ,P N CROSS SECTION END-SECTION 06.00 AND IS NOT INTENDED TO 13E A SURVEY i�LU LA f IT SHOULD BE 'USED:FOR'NO PURPOSE OTHER THAN THE SEPTIC SYSTEM`INSTALLATION. i s E TYPICAL 1 5OU GALLON _SEPTIC TANK r _ :. .. ---------..:.,,,. 1. _. 99 i :., � NOT TO SCALE ._ � , + y [` ['' (� C. LEGEND O (H 10 LOADING) , t . D-eox DENOTES, PROPOSED 104X 1 f4 s w SPOT GRADE O TEST HOLE i O 2.5 ELEV. 99.00 DENOTES EXISTING PERCOLATION TEST. E TEs � X 104.46 1`500 ol. f,5 a SPOT GRADE Date of Percolation Test, AUGUST 3, 2003 Septic Tank } P CRAW ' `Test Performed°B . CARMEN E. SHAY, R.S_, C.S.E;, L CK PL rBarnstable O.H. SPACE PROPERTY LINE Results witnessed By. WAIVER(, Per B l cInc. EXCAVATOR: Shay£nvironmenta Servi es, I , a P PROPOSED CONTOUR ` Percolation Rate. , Less Than 2 MPi 0 30 Below Land Surface � t _ 96 LOT #8 .�. _ LOT 6 T,-,— - -... �. Test Hole # 97 EXISTING CONTOUR No. I 6. Tolled LPXl'STINC„ Cesspool P 2 AEDRORM DEPTH SOILS ELEV. o ss.00 HOUSE DEEP TEST HOLE & Loamy €1s PERCOLATION TEST LOCATION Sand 'I I I 10 YR 3/2 A PROJECT BENCH MARK 6 FOOT STOCKADE FENCE � o-s a.za Graver TOP OF FOUNDATION Loamy ELEV.` = 100.00 (Assumed) Sand Driveway• l fo trz a/e �, LOT #7 THERE ARE NO WETLANDS WITHIN 200`,OF THE PROPERTY. 1 !1,840 Square Feet +/ 30 -- 134 B. :' '96.50 � v 4 R Medium ! sand g ___ _- ---- ---- -----------=------------- 99 2.5 Y 7/4 } a Ct13 � 105.00' P LOT P LAN PL UPGRADE Perc #1 1 OF PROPOSED SEPTIC SYSTEM , P Depth:to Perc:'30". to 48" _. - _ _ _.� PREPARED FOR -, Perc Rate- Less Tha 2 MPl Groundwater Not Observed No observed Es�1wT CHRISTOPHER COSTELLO ` ADJUSTED H2O Elev, None AT 40 FOOT RIGHT OF WAY) } 18 CU DDER ROAD 2 � OSTERVI LLE NIA Design Calculation �K Y:: PREPARED,,.: B s 1 n r r V ': Number of Bedrooms. 4 Proposed,`E Equivalent to 440 Gal. Da .: 440 Got./bay. a Min. a Tile , P � ,. �' y ( 1a? y � ? � s Garbage Grander. No ,• , LeachingCapacity Proposed: 440 Gol, a Minimum (Min. Per,Title u/� P y ._ P , tb y { '�} �. 11 R1'1.l,Li l ►' �. �,L 1.t7. �, T k - E. Septic an . . 2 x`440 Goi. a 880 USE 1 500 CAL tic Tank, /b_Y sip 0 20 40 _- 50 VICEINC. . H ENVIRONMENTAL SERVICES, I SOIL ABSORPTION . A' rn 'percolationmin./inch ,,, , S LARE Usrote of C2 .; Bottom Area. 0,74 al/sq. ft. x 432s . ft. 320 altons — RON1 99 � R;O. BOX ,62 7 Side Area. - 0.74' at. s `. ft. I� 188 ft. _i39.00 gallons 0 9 � 4 sq., 9 � � ; ... ! f S T E TH °MA 02536 EAST FALM©U r Providing: 459 gallons .; , � „ /7AR , .. _ `_.__' TEL` FAX,.. S08 5. 8 - SCALE.'. 1 20 / . 4 INFILTRATOR M AVI I DEPTH, Use. HIGH CAPACITY I ILTRA QR.CHA BERS, H NG A 2 EFFECTIVE DEP > , _ , ,,., O _ ATE_ AUGUST 3 2003 _ �. . 1 20 DRAWN BY. CES D _ , . , - . 'SCALE. ND '4 W x 7 L `TO BE USED WITH 4 OF WASHED STONE ON>THE SIDES A - ; P .DWG SHEET,.1 0 F 1 _ PROJECT SQ460 1"ILENAME. SD460 PP .DWG OF WASHED STONE ,ON THE ENDS. __