HomeMy WebLinkAbout0281 SCUDDER ROAD - Health tldde: Roan ,
Ostdvil?e
A= 139-012
I
No. I r 1 1 U ids, Fee /0 0.— /
Entered in computer:
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
Rpplitatton for Migoar *p5tem Co=stem
n i3ermit
Application for a Permit to Construct( ) Repair(�pgrade( ) Abandon( ) ❑Individual Components l
p _(
Location Address or Lot No.2 ( SC u&ev_ Owner's Name,Address,and Tel.No.
ld / f
Assessor's Map/Parcel Irv, _O DhJ l r/0[�IfO'
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
A.
Type of Building: (ovc = rvi vu p AAff0✓t, �nuwtvar ✓rvvl^ o' ��
Dwelling No.of Bedrooms �►u Sq 1L r,,c_4 of Size i C '°t h� sq.ft. Garbage Grinder (o ) ���� G v^���
Other Type of Building No.of Persons Showers( ) Cafeteria
Other Fixtures
Design Flow(min.required) -( 1 o gpd Design flow provided y�r7 gpd
Plan Date Number of sheets Revision Date
Title /
Size of Septic Tank 1 �'� i'�-�® Type of S.A.S. 3 Ghaa�• / t �1
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construeion 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 Bo of Heal
Signed Date ky
Application Approved by -44Date ( �d
Application Disapproved by: Date
for the following reasons
Permit No. U d /I —• .,•—, Date Issued
k
.+o•". No. I Q—' I O,t 4 `a�---�-a r 4a r Fee / y
a �� ' r Entered in com ut�
THE COMMONWEA. LTH OF MASSACH SETTS p
PUBLIC.-HEALTH DIVISION = TOWN,OF``BARNSTABLE,� Yes {
MASSACHUSETTSw
ppricatiou for Permit
Application for a Permit to Construct( ) Repair(✓ Upgrade( ) Abandon( ) Complete System ❑Individual Components
x
Location Address or Lot No.Z�l SCvci.�« ��. Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel O lh��� oO 77 ` A111)U,-
Installer's Name,tAddress,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building: (tl�o�e : Irk roar+]' rrvur �p�d+nlP�o✓� I �uwrNr iudr^ aI/v /f
DwellingNo.of Bedrooms fti re d rrCT�dn� P� 7 f jv r Ffjvn A�
_e u f P t Lot ize / sq. ft. Garbage Grinder
Other Type.of Building No.of Persons Showers( ) Cafeteria( ) '/ (o
Other Fixtures
Design Flow(min.required) L/ gpd Design flow provided �`�SI gpd
Plan Date Number of sheets 1, Revision Date
1
Title 1
Size of Septic Tank n U a Type of S.A.S. 3) Uv 6(4,,,be,,
Description of Soil
A
-i5
Nature of Repairs or Alterations(Answer when applicable)
s
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in y
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 Bo of Healt Y \
Signed 1 Date /n'1� /(-)
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. U 10 / Date Issued t/0
THE COMMONWEALTH OF MASSACHUSETTS
S,I BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( )
Abandoned( )by 5�e„p N f
at 2 21 I r G>Ii�t,Pr ✓Ifs n t Mi`AP has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. _?a/U — y� dated
Installer Designer
#bedrooms Ll Approved design flow 4/1/0 gpd
The issuance of this pe it shall not be construed as a guarantee that the system�i-111 ru c:ttimasesigned.
Date I� 2 ; , Inspector �-1-
No. J O/0 r Li �ri Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
lwigpo!gal 6pgtem Congtructfon Permit
Permission is hereby granted to Construct ( ) Repair (� ) Upgrade ( ) Abandon ( )
System located at
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Constru tion ust be completed within three years of the date of this e
h
Date i,{� 0 - Approved by +�V:, <
1
TOWN OF BARNSTABLE
LOCATION Z �v��e.c SEWAGE#
VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. f`j( �
SEPTIC TANK CAPACITY N?C
LEACHING FACILITY:(type) (size), A X
NO.OF BEDROOMS y HZ®
OWNER QAQt m fl^Le�
PERMIT DATE: COMPLIANCE DATE: — V'2—(d
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
i
car--
go
--� Az: 19
13Z� i BIZ
000 �y a 34v2
B 1° ca
ass 2
PREPARED BY:
Glen E . Harrington , R . S .
9 Leda Rose Lane
Marstons Mills , MA 02648
Tel: 508-428-3862
# 281 SCUDDER ROAD , OSTERVILLE
12'-1" 13'-3"
o BATH
BEDROOM BEDROOM j
FOYER N CL
GARAGE BREEZE- KITCHEN
WAY HALLWAY CL M.
CL BATH
OWN i�
BATH ; LIVING
DINING BEDROOM �
AREA ROOM
I BEDROOM 1 -2'
00
14'-5„
F I R S T FLOOR P LAN
/o/ si
NO SCALE
* . . Full Basement is. unfinished .
` 1 .
Town of Barnstable
`~ Regulatory Services
�. Thomas F.Ceder,Director
_ Public Health IDivision
.`� Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-8624644 Fax: 508-790-6304
Date: Sewage Permit# 10- Assessor's Map/Parcel I z
Installer&Desianer Certification Form
Designer: (Zl e w E• t1a rr i ii fo�!�S. Installer: s
Address: L e-dc, Ov f E'_ &oe Address: EG, Bfi x -7
PROW Jfl-,J -0i11f eW 0 4-Tqr
On was issued a permit to install-a
(date) (installer)
septic system at Z 8/ ft. v d da r- ed, &'- r based on a design drawn by
(address)
�r /���4�D�,,e s. dated
(desi er)
r/ 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. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State&Loc ations. Plan revision or
certified as-built by designer to follow. Stripout(if ed and the soils
were found satisfactory.
GLEN
ERIC 01�
t HARRINGTON 4
s Signature) No. 1070
t i < Co
TA!ate_
(Design s Si (Affix DesfgdWs Stamp Here)
LEASE P.ETUM TO BARNSTABLZ PUBLIC HEALTH DIVISION. CERTIFICATE
OF CQAP CE NOT BE ISSUED UNTII. BOTH = FORM AND
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
gAoffice formAdes4nercertification fa m doc
Town of Barnstable P# 13 �� Z
of ,
Department of Regulatory Services
Public Health Division DMASSate
t639• ,6�' 200 Main Street,Hyannis MA 02601
Date Scheduled b Time Fee Pd. OL)
i
Soil Suitability Assessment for Sewage Disposal
Performed By:
1Y 1Yl�sV� fy �H S f31n F'i S \
--z----�— Witnessed By: f/i J t w: _�J
r /l�
LOCATION& GENERAL INFORMAT O
s
Location Address ��Ui�Gf Owner's Name (/�/�ilL
Address
Assessor's Map/Parcel: Engineer's Name 0'�
NEW CONSTRUCTION REPAIR Telephone# 01?.9
Land Use I&J 1 UfIGV1 � Slopes(%) Q`? Surface Stones it/C3
Distances from: -Open Water Body. ! 0 ft Possible Wet Area .7 ft Drinking Water Well ft
Drainage Way ft Property Line Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
qyp ,9g � a
Q tSDt -_— ll
O I
� o
r
iwo a
W
D }
Parent material(geologic) ®���� L` - 'Depth to Bedrock.
Depth to Groundwater. Standing Water in Hole: •*�/ e— Weeping from Pit Face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: Se t ( Elm f
Depth Observed standing in obs.hole: In, Depth to soil mottles: 4. o "-e
Depth to weeping from side of obs.hole: In. Groundwater Adjustment ft.
Index Well# Reading Date: Index Well level AdJ,factor, Adj.Groundwater Level, a
PERCOLATION TEST Dote af xlme IIA14
Observation
Hole# Time at 0"
Depth of Perc �.B S 4 Time at 6"
Start Pre-soak Time @ ®'�® Time(9"-611)
End Pre-soak qr.jG 0
Rate Min./Inch Z
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed'on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first,notify the.
Barnstable Conservation Division at least one (1) week prior to beginning.
Q:\SEPTICVERCFORM.DOC 1,
i I
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soil Color Soil. Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
on istenc 96Gravel)
5 �6 �v
1 w C 1 M-C fia.r,d Z.r: -7 3 .vd
DEEP OBSERVATION HOLE LOG Hole# 2---
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
f �Q I ,� fo��J/2
3� aw and LOY
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Co i toncy,%Gravel)
DEEP OBSERVATION HOLE LOG Hole#
FfromSoil Horizon Soil Texture Soil Color Soil Other
(USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consi to I
Flood Insurance Rate Man:
Above 500 year flood boundary No yes
'Within 500 year boundary No Yes
Within 100 yea,.^cad boundary No._,,,,, Yes
Death of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious`ma�erial exist in all areas observed throughout the
area proposed for the soil absorption system? --��!
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on l® / (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with .
the required training, expertise and ex rience described in 310 CMR 15.017.
Signature � *7ZI 0
Date
Q:\S.EPTlCWERCFORM.DOC
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I A , �-,
m / IL
DATA
�� \ s ,,r�'xr �•. .,r-�^'" -.^�`°ia'.� r~� „�� .�-�1a-'
Town ofRa" kns
Regu11atory Services Department �'ca j
13AFNSTABLE
9� 0 9. �� Public Health Division
200yMain Street, Hyannis MA 02601 2007 m
Office: 508-862-4644 Thomas F.Geiler;Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 70083230000251782893
7/26/2010
Audrey McInerney
281 Scudder Road
Osterville, MA 02655
ORDER TO COMPLY WITH STATE ENVIRONMENTAL.CODE, TITLE 5
The septic system located at 281 Scudder Road, Osterville MA was last inspected on
May 27, 2010,by Robert Paolini, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system"Failed" under the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
Single cesspools automatically fail in the Town of Barnstable
You are ordered to repair or replace the septic system within Two (2) years from the date
you receive this•notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action. ,
PER ORDER 0 THE BOARD OF HEALTH
as cKean R. H S C O
Agent of the Board of Health
0 pal
o
i Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments
M 281 Scudder Rd.
Property Address
Audrey McInerney
Owner Owner's Name
information is required for Ostervllle Ma.. 02655 5/27/2010
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on.this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer, use 1. Inspector: VVUIII UUU
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
r� P.O.Box 763
Company Address
",Centerville Ma. 02632
'e"A! City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
.. sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (.310 CMR 15.000). The system:
HZ= ❑IPasses ❑ Conditionally Passes ®Fails
t ❑T Needs Further Evaluation-by the Local Approving Authority
5/27/2010
Inspect 's Slgn Vure V 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.
I
t5ins-09/08 �` Title 5 Official Inspection Form:Subsurface Sew a Disposal System age 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 281 Scudder Rd.
Property Address
Audrey McInerney
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ 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):
l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
j
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 281 Scudder Rd.
Property Address
Audrey McInerney
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 281 Scudder Rd.
Property Address
Audrey McInerney
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. Cityrrown 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 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 281 Scudder Rd.
Property Address
Audrey McInerney
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000g pd.
® ❑ 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.
l5ins•09108 Title 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
281 Scudder Rd.
Property Address
Audrey McInerney
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
281 Scudder Rd.
Property Address
Audrey McInerney
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ® Yes ❑ No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ 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: 5/27/2010
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
281 Scudder Rd.
Property Address
Audrey McInerney
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system _
® Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
A-,
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
G M , 281 Scudder Rd.
Property Address
Audrey McInerney
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1953
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3' 6'
feet
Material of construction:
® cast iron ❑ 40 PVC ® other(explain): Orangeburg
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 281 Scudder Rd.
Property Address
Audrey McInerney
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
tw
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
281 Scudder Rd.
Property Address
Audrey McInerney
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 281 Scudder Rd.
Property Address
Audrey McInerney
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. Cityfrown 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
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09108 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 281 Scudder Rd.
Property Address
Audrey McInerney
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration two single cesspools
Depth—top of liquid to inlet invert dry dry
Depth of solids layer
1' 1'
Depth of scum layer
0" 0"
Dimensions of cesspool Both 6'x8'
Materials of construction Concrete Block
Indication of groundwater inflow ❑ Yes ® No
t5ins•09/08 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
u - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 281 Scudder Rd.
Property Address
Audrey McInerney
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. Cityfrown 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.):
Sandy soil.System shows signs of hydraulic failure.Both have been full at one time.
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Map Page 1 of 2
Town of Barnstable Geographic Information System
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• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
281 Scudder Rd.
Property Address
Audrey McInerney
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of CP 10'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 late#2 annual ranges of
P 9
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
281 Scudder Rd.
Property Address
Audrey McInerney
Owner Owner's Name
information is required for Osterville Ma. 02655 5/27/2010
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
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ARCHITECTURAL DESIGN
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- _ • NOTES:
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54
. DATE bnvn
B.M. = 26.97' APPROX. NGVD 26.57' Bay St.
N ON C.B. 1 f n d. P� 3-20• DIAM. ACCESS MANHOLES •
26 7,'
11' 2 W tea Rd
SITE PLAN 7.50 B. M . es
C.B. 1 fnd.
SCALE: 1 " = 20' �
7.75' ,
CONTOUR INTERVAL=2' \ O t <°°a
VO •'• N
G of atr _ m THE ACCESS COVERS FOR THE SEPTIC TANK,
C, edge 7.5 ' INLE1 OUTLET DISTRIBUTION BOX AND LEACHING COMPONENT 9
7 96 SHALL BE WITHIN 6" OF FINISHED GRADE. ¢� Q-
' 27.58' X X 25.65' ;; INSTALL TUF-TITE GAS BAFFLES OR EQUAL SITE Jaa &
818' OD ON ALL OUTLET TEE ENDS y v ^^yam°
,�p�5• T.H. :•:•+:tii: Sa:.�•;v•a�.: ''.!.+. ?:. !r, a\\`�y
is ..,s;••;S: :�.� L
27.87' 'ati}r:::•
df 27 18' ven :.;;: STEEL REINFORCED PRECAST CONCRETE a
s.1s :'``'i PLAN VIEW
.16 .: iy i.p.
0 3-20" REMOVABLE COVERS
X 27.96 �O
27.73' O T.H. #1 '°`v, ,.: �� . :::- ;. e"
26.0 ' -.3r-m>r'clearance
to '' ;�.�• "O S TE R VI LLE�WI A N N O"
tJ1 INLET B• mn•1 3 min. filet to outlet a.� .
,�o� 5.55 ` ' .- T
' Xo �G ? to•min. Llquld I" OUTLET
@~heoa g�°Je\ cell, /t etg C.O. °���' �o os °°"' -�. era aeain NO SCALE
See Note #14 v+a s0 70
,,• a� • •'--s
� - j• - s ' CONSTRUCTION NOTES
11'-0• W-2•
�oo $� CROSS-SECTION END-SECTION 1. Contractor is responsible for Digsafe notification
0. 2 \NG and protection of all underground utilities and pipes.
N� r TYPICAL 1500 GALLON H-20 SEPTIC TANK 2. The septic tank and distribution box shall be set
25.00' e e 6 V`IE 25.29' X 23.8 level on 6" of 3/4"-11/2" stone.
Og oa o NOT TO SCALE
3. 'Backfill should be clean sand or gravel with no
stones over 3" in size.
oage de 4. This system is subject to inspection during installation
09, �,g�ot gt° to Glen E. Harrington, R.S.
s�oa p GENERAL NOTES 5. The contractor shall install this system in accordance
25.38' X 1. ADDRESS: #281 SCUDDER ROAD, OSTERVILLE with Title V of the Massachusetts Environmental Code.
2. ASSESSOR'S NUMBER: MAP 139 PARCEL 012 6. If, Burin installation the contractor encounters an
X 23.55' 3. DEVELOPER'S LOT: LOT #5 9 Y
25.53' X O CBSSp OI 4. TOPOGRAPHIC INFORMATION WAS COMPILED FROM AN ON THE GROUND INSTRUMENT SURVEY. SOIf conditions Or site conditions that are different
5. TOWN WATER IS PROVIDED TO THE SITE & SURROUNDING PROPERTIES. from those shown on the Soil log Or in our design
C 17.12
6. BORDER OF VEGETATED WETLANDS LOCATED BY GLEN E. HARRINGTON, R.S. the installer shall halt installation and immediately notify
0 �� G 7. REFERENCE PLAN: PLAN BOOK 46 PAGE 11 Glen E. Harrington, R.S.
40 25.44 X 25.41 X K 9
F` 3? WOR 7. No vehicle or heavy machinery shall drive over the
�i� X 23.47' S+ X 23.39' X 23.53' L�N11� OF K 94' �y�� septic system unless noted as H-20 septic components.
co„ BAN 11
_ a P �F g 8. The contractor shall contact the Designer and Board of Health
22.56'®cesspool .47' .fnd.
T� at least 24 hours in advance to inspect and certify the system.
'.I�
X 23.13' 9. All piping shall be SCH 40 PVC
2 LOT 5 7 6, 10. No wells are located within 150' of proposed SAS.
22.18' X AREA= 18,295f sq. ft. 11. This design plan shall be used for the septic installation only.
12. Install observation port to 3" of grade and vent in SAS, as shown.
H 13. The garage interior plumbing shall be relocated to allow an outlet,
SOIL EVALUATION & PERK TEST 7.08 �,/ �1� 5��� as Xwn. „
Date of SOIL EVALUATION: AUGUST 26, 2010 VEGETATED WETLAND l,wr3 �„ r 14. Encase the 4 Sch 40 PVC building sewer with 6 dia. SCH 40 PVC
Desi n Calculations �r
Evaluation Performed By. Glen E. Harrington, R.S. 11.55 / g �� �t, ,- L to provide 10 feet of protection at sewer/water line crossing.
Excavator: ERIC STEVENS, STEVENS CONSTRUCTION 7.14 Number of Bedrooms: 3 Existing Hf
Percolation Rate:< 2 mpi assumed, 24 gals applied during presoak 15. Pump and fill abandon existing cesspools in accordance
Witness: David W. Stanton, Rs., BOH Agent � Garbage Disposal: Not allowed with this design. y'° 1�y tw`�•
Septic Tank Capacity Required: 330 Gal./Day x 200% = 660 gals. N' with 310 CMR 15.354.
OF Septic Tank Capacity Provided: 1 500 gal. H-20 (min. per Title V) d 1 6. Contractor shall notify the Conservation Commission to inspect
Test Hole Test Hole h� I ' Y P
No. 1 No. 2 ORp� \p Leaching Capacity Required: 330 Gal./Day 'r �� cesspool abandonment and main sewer lines are connected up.
WIN SOILs ELEV. DEPTH <PR) 17. Use Acme Precast 1,500 gal. H-20 septic tank, 5-Hole H-20
SOILS ELEV. P O\v Application Rate for <2 min./inch = 0.74 gal/sq. ft.
o s.7s' o ,� .3s' � ` Proposed Leaching Structure: 1-33.5' x 13' x 2' Leaching Trenches 5.5 ' \ Bottom Leaching Area Provided = 435 sq.ft. distribution box and three H-20 500-gal chambers or equal.
_ 1oYR,�3/2 0myR3%2 `V Side Leaching Area Provided = 186 sq. ft. I rf
get KVI Total Leaching Area Provided = 621 sq. ft. x 0.74 gpd/sq.ft=459 gpd. LOCAL UPGRADE APPROVAL VARIANCE REQUESTED: r
W . Leaching Capacity Provided =459 gpd. > 330 gpd. required.
2e loins 3.75' 30• !Weec
es' // 310 CMR 405 (1)(b): A VARIANCE IS REQUESTED TO ALLOW THE PROPOSED SAS
�• cl c, PERK JEST #13042 TO BE CONSTRUCTED APPROXIMATELY FOUR FEET FROM GRADE IN LIEU OF THE
P � mwdee MW40 DEPTH: 36-W REQUIRED THREE FEET. A VENT WITH CARBON FILTER IS PROPOSED.
25Y7/3 BEGIN SOAK: 00:00 MIN
2.SY7/3 END SOAK: 8:00 MIN
TIME: aDo MIN.- UNABLE TO SOAK. LOCAL UPGRADE APPROVAL VARIANCE REQUESTED:
120• 5.7W 138• 4.SW USE <2 MPI FOR DESIGN PURPOSES
No Observed Ground water 310 CMR 405 (1)(g): A VARIANCE IS REQUESTED TO ALLOW THE FORCE MAIN AND
MAIN SEWER LINE TO BE INSTALLED WITHIN 10 FEET OF A WATER SUPPLY LINE.
Soil Evaluation Certification SCH 40 PVC ENCASING SHALL BE INSTALLED FOR A MIN. 10 FEET OF PROTECTION.
I certify that on October, 1995, 1 have passed the soil evaluator
examination approved by the DEP and that the analysis was performed by PROPOSED SEPTIC SYSTEM REPAIR
me co 'stent with the required training, expertise and experience described
in 31 15 r PREPARED FOR
STEVENS CONSTRUCTION
GLEN E. HARRINGTDPrR.V _
AT
SYSTEM PROFILE Provide 4" dia. SCH 40 PVC 281 SCUDDER ROAD
vent with carbon filter
Existing Dwelling
Not to Sale (OSTERVILLE) BARNSTABLE
5 HOLE H-20
T , of Fndn. F.Iev.u20.73 ; DIST. BOX
Existin Grade = 26.0 Finished grade over system=2% slope away Existing Grade = 26.5't OWNER: DAVID DOHERTY
- LEGEND
CELLAR Septic tank covers must be D-Box cover shall be One chamber cover shall be Min. 2"-1/8"-1 2" Double-Washed Stone
WALL S = 02 within 6" of finished grade within 6" of finished grade within 6" of finished grade or goo-textile filter cloth _ Approxi of location �'('AOFMA PREPARED BY:
S=.01 To of Peastone Elev.=22.6't wa�er I ne tG`
wo =+" - PROPOSED Level for 2' S=0.01 ft/ft Invert Elev.=22.08' -18- Existing contour G Glen E. Harrington, R.S.��x,mt."'`"�", House-34 _. _ ,_.- ,
Garage-64' 1500 GAL. 9' 21' New 1,500 gal. I±RI 9 Leda Rose Lane
Ex. House SEPTIC TANK P-22.29' 0 0 C 0 0 0 24" septic tank H IN 7o arstons Mills, MA 02648
In H-20 eP Existing cesspool p el: 508-428-3862
Prop. Garage Install Gas gof a Facility Elev.=20.08' (to be pumped & removed) F
Inv. elev.= 24.08' Inv. elev.=22.80' or a ual = G{S•T Fax: 508-428-3862
3/4"-1'k" Double-Washed Stone 5' Min. required, 5.2' provided o•p• Observation Porte
6" OF 3/4"-11/2" STONE LEACHING CHAMBERS S =20' DRAWN BY: GEH DATE: 5 OCT 2010
6" OF 3/4"-11/2" STONE Hole #2 lev.=14.85' C.O. Cleon-out DATUM: Approx. NGVD FILE: StevensDoherty SHEET 1 OF 1