HomeMy WebLinkAbout0215 SEA VIEW AVENUE - Health a 215 Seaview Ave
Osterville °
A= 138-017
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TOWN OF BARNSTABLE
IOCATrON
VILLAGE QST-e(%MU ASSESSOR'S MAP&PARCEL
IN�R'S NAME&PHONE NO. � r�:rGIL 0d,,0,n yL
SEPTIC TANK CAPACITY 15 00 + 1000
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LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS �D
OWNER
PERMIT DATE: ATE:1 1 1 `1 1
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
J f J F J f•~ f f J
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27 4
Sea view Ave.
TOWN OF BARNSTABLE
LOCATION,e,f/S ,s.Vy«vs �4e SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. ai" 1
SEPTIC TANK CAPACITY 4L4__Q 6-1 !coo ed W-2w
LEACHING FACILITY: (type) f Ga L (size) d9ol `X 1,1 Xa
NO. OF BEDROOMS
BUILDER OR WNER
PERMITDATE: f iy COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility r 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) f�r� �' Feet
Furnished by
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67- 1-7&t
No. Fee Q
THE COMMONWEALTH OF MASSACHUSETTS' Entered in computer: -t'
•a es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTi4BLE, MASSACHUSETTS
01pprication for Oigoal 6potem Conotruction Permit
Application for a Permit to Construct(,—)-Repair( )Upgrade(---)'Abandon( ) �omplete System O Individual Components
Location Address or Lot No. Z1 Secl 2w Atv e• Owner's Name,Address and Tel.No.
Assessor's Map/Parcel t :3 215` Sec vtf_- Ave-
AM-7 1`7 04-,:;v
Installer's Name,Address,;nd Tel.Ng. Des er's Name,Address and Tel.No.
7 7/` crv�l�e QZ(eSS 58$-4Z8'�3ti�
Type of Building:
Dwelling No.of Bedrooms( Lot Size 0.S(o Au -sor t. Garbage Grinder(r
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures I 01�0 I
Design Flow �,0 t I 1 I i-t'� gallons per day. Calculated daily flow C2(00 gallons.
Plan Date Mcw 1 , 00 Number of sheets '7_ Revision Date
Title _ 51'rC ?kn l�rwobed
Size of Septic Tank Z00 6AL, Type of S.A.S.1'!900 (ok Chcm er-, L-, F16c 0
Description of Soil-tj" btkiek WYKZ%Z cg6= 8 je, &LAIc 2� 10yky/z (0A,Aj1L-
10-2,5" 2, LA-161, 101KII(a Mr=Z� SAN*b w/samc FtNt--, �i3`Ci ir�y Io72 wr moo, so�_'s
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a`Certifi-
cate of Compliance has been issued b Is Bo d al 9 /w��
Signed Date
Application Approved by vw S_ Date
Application Disapproved fo the following reasons
Permit No. �:2 ua 1 Date Issued
Fee t5�0 /�
k THE-COMMONWEALTH OF MASSACHU�E*VF ,-' tJ Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BAr NSTA'SLE., MASSACHUSETTS
2pplication for O.igpool bpotemc Construction Permit ;
Application.for a Permit to Construct(,..Repair( )Upgrade(--'7 Abandon( ) Rr6omplete System ❑Individual Components
Location Address or Lot No. ZI 5 ec"V i eW ►� P. Owner's Name,Address and Tel.No.
OS�r� �1�
" Assessor's Map/Pazcel Av2..
Installer's Name,Address,jand Tel.No./'Grp Designer's Name,Address and Tel.No.
fl/ / C.-l/�✓e'T `�ui�Nq r� �nJiilfcr�hj
7 71 ���� 0. crvft MA oZios� �scd-clzB- :S�IQI
'.,Type of Building:
Dwelling No.of Bedrooms 62 .- Lot Size d-S Au Garbage Grinder(✓'X"�
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures ► I
;w
Design Flow i C y 5- I I gal ods per day. Calculated daily flow gallons.
Plan Date fylk I I Z, 706`( Number of sheets 7 Revision Date
Title S ITC ?Iw rl 1�r OeObPCA 5fQ�it via roe_
Size of Septic Tank Z000 EAC.. Type of S.A.S.9=Soo (cAk,
Description of Soil-04' ol-ki-9, uAe,tf Bid' It lAW9, ioyiZ4/z �ir�e�,rvQ w/ Sar�� o2(oA.)J%L
lr�yi (L oYi:`i�(e r�1tD SrlNil �I�` CI Crlye(Z Io"IK (0& r31EJ. \AV6
1
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Ceertifi-
cate of Compliance has been issued b s B o d o f Hiealth,.4 (�/ '�
Signed�l_! r Date 7
Application Approved by /a L 6�j ''W _ � t f. �Date " I/1 04
Application Disapproved foY the following reasons J
Permit No. -)tlit Date Issued
i T
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 �'�
at 7.117 .SEA V IF-uJ AFL has been constructeA in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.-001/-a q1 dated / V /v
r
Insfallerr__._-"-----��.;____ Designer
The issuance of this permit shall not be Me
as a guarantee that the system'willyfunctionas designed14,V/
Date �1 t Inspector � 1 J(l vt. I�
No. Q 0 — t Fee S()
THE/COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Oiopozal *pgtem Construction Permit
Permission is hereby granted to Construct(--)Repair( )Upgrade(--)Abandon( )
System located at Z►S- SEA, U IEw PVC..
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construct/io 'm�/ust be completed within three years of the date of is pe 't.
Date: S 7 U 7 Approved by �. IA r. 0�.
f
y Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 215 Sea View Ave
Property Address '
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name T"
information is
required for every Osterville Ma 02655 2/10/18
page. City/Town State Zip Code Date of Inspection
to
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 s/ /C203 1
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael DiBuono
use the return Name of Inspector
key.
DiBuono Sewer and Drain
Company Name
35 Content Ln
Company Address
Cotuit MA 02635
Cityrrown State Zip Code
508-364-9587 SI 13522
Telephone Number License Number
r
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 16.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Ap ving Authority
2/10/18
spector'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
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
215 Sea View Ave
Property Address
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name
information is required for every Osterville Ma 02655 2/10/18
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
N ry Y N
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:
System contains a 1,000 gallon septic tank as well as another 1,500 Gallon septic tank. A concrete
distribution box and 9 Leaching chambers. All components are H2O
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
215 Sea View Ave
Property Address
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name
information is required for every Osterville Ma 02655 2/10/18
�
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
215 Sea View Ave
Property Address
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name
information is required for every Osterville Ma 02655 2/10/18
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 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 '/z day flow
t5ins•3113 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
M 215 Sea View Ave
Property Address
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name
information is required for every Osterville Ma 02655 2/10/18
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.
❑ E 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
215 Sea View Ave
Property Address
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name
information is required for every Osterville Ma 02655 2/10/18
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): 6 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 215 Sea View Ave
Property Address
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name
information is required for every Osterville Ma 02655 2/10/18
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: Vacant
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 d 215 GPD
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
215 Sea View Ave
Property Address
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name
information is required for every Osterville Ma 02655 2/10/18
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:
Not Provided
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 s e r n if
El Shared y (yes o o) ( 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 215 Sea View Ave
Property Address
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name
information is required for every Osterville Ma 02655 2/10/18
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:
10/14/04
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: 1.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1,500 And 1,000
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
w - Title 5 Official Inspection Form " F
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
215 Sea View Ave
Property Address
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name
information is required for every Osterville Ma 02655 2/10/18
page. Cityrrown 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
24"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
42"
Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick
How were dimensions determined?
Tape Measure
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•3/13 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
°�M •'' 215 Sea View Ave
Property Address
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name
information is required for every Osterville Ma 02655 2/10/18
page. Cityrrown 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
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form _
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
215 Sea View Ave
Property Address
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name
information is required for every Osterville Ma 02655 2/10/18
page. Cityrrown 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 Level and at normal level
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.):
* 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
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
215 Sea View Ave
Property Address
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name
information is required for every Osterville Ma 02655 2/10/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 9
❑ 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.):
No sign of failure
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
215 Sea View Ave
Property Address
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name
information is Osterville Ma 02655 2/1 /1
required for every 0 8
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 215 Sea View Ave
Property Address
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name
information is required for every Osterville Ma 02655 2/10/18
page. Cityrrown 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
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
°M 215 Sea View Ave
Property Address
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name
information is required for every Osterville Ma 02655 2/10/18
page. Cityrrown 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: 9+
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. 10/14/04
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:
Test hole data on plan
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
2/10/2018 Assessing As-Built Cards
TOWN OF BARNSTABLE.
LOCA71ON a_4J r SEWAGE 0 o770
VILLAGE /3r"11, ASSESSOR'S MAP 8r LOT A
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 4L4-o Gal /,/- r y coda ea 6/•.30
LEACHING FAcuxry:(type) so 6e (size) S.�X,0 Xs�
NO.OF BEDROOMS (s
BUILDER OR 1
PERMITDATE: f iy COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility r Feet
Private Water,Supply Welland Leaching Facility (If any wells exist
on site or within 2W feet of.leaching facility) Feet
Edge of Wetland and Leaching Facility(U any wetlands exist
within 360 feet of I hing facility) /OB a Feet
Furnished byt<.-
QQ Frod f
O
O
7
9/ 37 6 aT yr'
JJ,
y� 67- .29'
p7-1�
�y. r7, C 7' i7ZI
http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=138017&seq=1 1/2
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 215 Sea View Ave
Property Address
MARCHESE, KATHLEEN J & MICHAEL J
Owner Owner's Name
information is required for every Osterville Ma 02655 2/10/18
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
215 Seaview Ave
Property Address
Bellingrath
Owner Owner's Name
information is Osterville MA 02655 November 7, 2012
required for
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 n
When filling out
forms on the 3
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell
cursor-do not Name of!nsnector
use the return
key. Septic Inspection Services Co.
Company Name
r� 189 Cammett Road
Company Address
Marstons Mills MA 02648
�^m City/Town State Zip Code
508-428-1779 _ S1 12855
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 ❑ Fa4� p-
❑
r;:r a 1-3
Needs Further Evaluation by the Local Approving Authority ,��� w
ti
a ,
November 7, 2012 Job# 12-266 ,rr vtl
:-
In pector's Signature Dale
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.
15ins-11/70 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 17
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
215 Seaview Ave
Property Address
Bellingrath
Owner Owner's Name
information is Osterville MA 02655 November 7, 2012
required for
every 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:
® 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:
Tanks were not in need of pumping at time of inspection, leaching system showed no evidence of
surcharge or saturation.
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):
15ins-11/10 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
215 Seaview Ave
Property Address
Bellingrath
Owner Owner's Name
information is Osterville MA 02655 November 7, 2012
required for - --------------------- ---
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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
215 Seaview Ave
Property Address
Bellingrath
Owner Owner's Name
information is Osterville MA 02655 November 7, 2012
required for
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 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
El ® 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
!Sins-11110 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
215 Seaview Ave
Property Address
Bellingrath
Owner Owner's Name
information is Osterville MA 02655 November 7, 2012
required for
every 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-
❑ ® Y P 9 Y 9
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•11110 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
215 Seaview Ave
Property Address
Bellingrath
Owner Owner's Name
information is Osterville MA 02655 November 7, 2012
required for
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
'❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 6 Number of bedrooms (actual): 6
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660
15ins-11/10 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
w 215 Seaview Ave
Property Address
Bellingrath
Owner Owner's Name
information is Osterville MA 02655 November 7, 2012
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
1
Number of current residents:
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d N/A Irrigation
g ( y g (gp ))' system.
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: Currently
Occupied.
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
Grease trap present? ❑ 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•11110 Title 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
215 Seaview Ave
Property Address
Bellingrath
Owner Owner's Name
information is required for Osterville MA 02655 November 7 2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Last pumped 10/5/10
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:
® Septib 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•1111110 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
215 Seaview Ave
Property Address
Bellingrath
Owner Owner's Name
information is required for Osterville MA 02655 November 7, 2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1.
Depth below grade: feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:g years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal & 1000 gal.
Sludge depth: 2" / 0-1
t5ins-11/10 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
215 Seaview Ave
Property Address
Bellingrath
Owner Owner's Name
information is required for Osterville MA 02655 November 7, 2012
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 2 / 0
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.):
First tank had minimal accumulated solids and second tank had liquid only. All tees were intact and
clear.
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
15ins•11110 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
215 Seaview Ave
Property Address
Bellingrath
Owner Owner's Name
information is required for Osterville MA 02655 November 7, 2012
every page. Cityrrown 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
El 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
215 Seaview Ave
Property Address
Bellingrath
Owner Owner's Name
information is required for Osterville MA 02655 November 7, 2012
every page. Cityrrown 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.):
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:
15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth f
t o Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
215 Seaview Ave _
Property Address
Bellingrath
Owner Owner's Name
information is required for Osterville MA 02655 November 7, 2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: Nine 500 gal
drywells.
❑ 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.):
Area of SAS was probed with no evidence of saturation found.
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•11/10 Title 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
�. 215 Seaview Ave
Property Address
Bellingrath
Owner Owner's Name
information is required for Osterville MA 02655 November 7, 2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
15ins-11110 Title 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
215 Seaview Ave
Property Address
Bellingrath
Owner Owner's Name
information is Osterville MA 02655 November 7, 2012
requiredfor ----- —.-........- --....... ._..._._...........__..._......_._..... ...... --- --- - ----
every page. City/Town State Zip Code Dale 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
n rlrawinn attarhari cannr�3hmhi
31
% %
27 4
F
See view Ave.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
215 Seaview Ave
Property Address
Bellingrath
Owner Owner's Name
information is required for Osterville MA 02655 November 7 2012
every page. Cityrrown 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: 15+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:
Open water at rear of property is considerably lower than SAS.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 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
215 Seaview Ave
Property Address
Bellingrath
Owner Owner's Name
information is Osterville MA 02655 November 7, 2012
required for
every page. Cityrrown 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
ISENT BY: MATOLOTTI CONST; 5084289399; NOV-4-04 15:30; FACE 213
Y Town of:Barnstable
I
Regulatory Services �I
aex+xcront�;1< ) Thomas F. Creiler, Director
Public Healfl.Y Di"VISIOU �
'Ihomas McKean,Director
200 Main Street,I;tynnuis,t17A 026@I
Office: 508-862-4649 Fax: 508-790.6304
Installer&Desi aer Certiflc;ation Form
Date:
Designer:
f
CC .
Desi i7 �►Vli, �»
�
Address: P 0 6a-u 7 RX,rU1-Pcd Address,
Gse.Ny,'ll e,y»?4
i
Cart ��� was issued.a petrti+,ioastail a
(date) (in�aPltrr) i
Septic system at__�� � a l" 0 6P"4`e based on a desigiz drawn by
ssJ +
dated
(designer)
X_ I certify that the septic system referenced above ttias installed ut�st�sa�tially S�cwtduig to
the design, wl�i,ch may include minor atppro'vcd Changes such ai later4I rzlouation of-tie
distribution box and/or septic tank.
I
I certify that the septic system referenced aboyo was installed(with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the sentio system,) but in accordance with State s . i;ocel Rea ?ation . Plan revisiur�or
ceitified as-built by designer to follow.
OF
% �'•�n
SU
(1t�talter's Signature) .�..�.. � C!-JOL �
i
(Designer's 5ignaiure) (.Affix ICere)
PLEASE RE,TURN TO )3AILNSTABLI,,*.11UBLIC%14LA.I.,TII DIV�k TON. �CERTIFICAT
OF. COMPLIANCE V4'ILL NCD'i k3E, ISSUED UNTIL BOTH 'Z IS 1+GIL'V£ AND AS-
13UILT CARD AREI RE'CI+;�:'4 ED D 'I'l:il;l3AR�T5�'ABLI�PUBLI ' 0q!1 ' TIT IV SIGN
TIIANI K YOU.
Q:tica':t'V9epiir/Dcsigner Certification Faun i
�1
TOWN OF BARNSTABLE
LOCATION �s
SEWAGE # �
VILLAGE .���d� ASSESSOR'S MAP & LOT • -.t��
INSTALLER'S NAME&PHONE NO. /�. l, y2 - Y1
SEPTIC TANK CAPACITY fir } e 1-.zr OBfl G"c L �•�t�
LEACHING FACILITY: (type) 5Zc C L GHQ;y�.f:� �� (size) 1,-7
NO. OF BEDROOMS
BUILDER OR WN_�E/R '� L,:;�•, �5
PERMTTDATE: s/�� COMPLIANCE DATE: fl l L! G� L
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 j
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of le ching facility) /6d Feet
Furnished bye-�.Y �y /
i
33
i
Q
O
02.'fig L 6-.2a
/J3-
e 7-
}
_ TOWN OF BARNSTABLE
LOCAT_ON � �r i�.v'J A uj s. # 5�
VILLAGE S 1- ("V ASSESSOR'S MAP&PARCEL
IN�'S NAME&PHONE NO S u ��'G1� l.t�'�l t �. ( 0- 11'l
SEPTIC TANK CAPACITY i S 00 +- {OCO
• i
LEACHING FACILITY: (type) 1 1�CLyh!-,2.(`� ��> (size)
NO. OF BEDROOMS
OWNER
PERMIT DATE: ATE:-1
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
31 /
21
27 4
US
�s-z for" ^� " '" •� •, t -�*'r�', �'�a.Y�y R-0°
c`� .. ...... .f•.3r
F ..r. ,..
f
Sea vie veII
t
I
y
IN.
Lill
,�,.1 �/V'U_ � it •. -.�- .i
l
y '
{Y
v�
I
1
r�♦ j
A
f �
e
c
FiHsh Gmde _ t ,
TEST HOLE - I
NOTES
3 ;vta t PERFORMED 9.:rhn = ��Filter � 1� SULLIVANENG Water Supply For'This Lot is Municipal Water.
IP: MED BY SULLIV 1
CompactedF11 -Ea6ric r 2. Location of Utilities Shown on This Plan Are A rox.
--i--- MAY 7,�.004 PP
Min _ Y LAWN EL_22.0 At Least 72 Hours Prior to Anv Excavation For This
3 ` -- -- 1'8"-1/2" O LAYER IOYR 2/2 Project the Contractor Shall Make the Required
Pea Stone
-- VERY DARK BROWN Ncitilicatioii to Did Safe(1-888-34 -7233)
811 LOAMY 21.3 3. The Contractor is Required to Secure Appropriate:
3. - A LAYER 10YR 4/2 Permits From Town Agencies For Construction
DARK GRAYISH BROWN Defined by This Plan.
LEACHING \ ; 10" FINE SAND W/ SOME ORGANIC 21.2 4. Install Risers to Within 12"of
" CHAMBER ; B LAYER 10YR 4/6 Finished Grade.
I 3/4"-1 1/2"
H-20 rouble Washed DARK YELLOWISH:BROWN 5. All Structures Buried:Four Feet or More or.Subject
Stone to Vehicular Traffic to be H-20 Loading.
_ 35" MED. SAND W/SOME FINES 19.1-
J C 1 LAYER 10YR 6;6 6. Septic System to be Installed in Accordance With
- 4'-10^ BROWNISH `.FELLOW 3 a0 C1VI:R 15.00 Latest Revision and the Town of
93" MED: SAND 14.3 Barnstable Board of Health Regulations.
12 C2 LAYER 2.5Y 6/4 1. All Piping to be Sch. 40 PVC.
CROSS SECTION OF CHAMBER LIGHT YELLOWISH BROWN 8. Septic Tank Shall be a 2000 -Gal.,2 Compartments.
125" MED. SAND 11.6 The First Compartment Shall.Have a Volume of Not
NOT TO SCALE NO GROUNDWATER Less Than 1320 Gal. And The Second of Not Less
OF } Than 660 Gal.
9:`V4here�er Sewer Lines Must Cross Water Supp v
R� Lines, Both Pipes Shall Be Constructed of Class_]R9
Pressure Pipe And Shall-Be-ressure Tested To
1 .29733
CIVIL Assure V/atertghtness._.-
Design Data
FT EL.`.24.0 � Single Family -6 Bedroom
F.G.EL.22.0
F.G.
r
- .EL...,_.)
- -- ----- -- ---� _-----._ With Garbage Grinder
- See rate 4(typ.) Daily Flow= 110 x 6 =660 GPD
C �`\ Septic Tank: 660 G:PD x 300% 1980 IJPI3
EL.zoo ��_ Use 2t3AH-G llon H-20 Septic Tank
V aries ; t.,I S�✓ UUV+,'
_ Top 1-1.H.0 in)
EL.18.0 _`'-- _ p
Garton Leach,
Area
Septic Tank l'y /� EL.1;.6
H 20 �✓ Flow Equilizers-.1 -_-'� 150%x 660 GPD/0.74 = 1338 SF Required
As R.=quired I.15.9 Sidewall=2°x 2(12'+82') =376 SF
�C 0 (3/uV O qk w� ; Bottom Area= 12'x 82'=984. SF
.. iVItCiir C� a eot El.149 _ 1360 SF total ProvidedBeddinga'T :'Li-
Ch `A•4 �ca� f � / Su 2 74o kfiaffels IfEnc.untered Remove$Replac.
ill Unsuitable Soils Within 9of
s Pear Title Alen The Outer Perimeter oFTheSystem Leachinn Chamber
I III f�I
.Desi(i .('-��
DEVELOPED PROFILE OF MOPOSIED SEPTIC SYSTEM All Pipes to be Schedule 40. Use
-- Groundwater E12.�_ 9-tiOO Gal. Leaching Chain -s ffi a
Pe*.T.i 3.Maps
NOT To SCALE Per
Stone Field as Show-11.
Revision: Relocated S.A.S._ I-09j20 04
Title: 'repared By: _-----_ Prepared For:
SITE PLAN
Cate: May 12, 20C4
PROPOSED SEPTIC- UPGRADE Sullivan. EnCineerirl�, 1nC. a----- m
PO Box 659 r Priscilla Q. Bellingrath
t4T 215 See View Avenue
215 SEA 1/IEW AVENUE0stervil e, MA 02655 Scale: . As Noted
28--
('S06)428-3j44 (.5a8)428 3115 fax Osterville, >/IA. 02655
BAR�ISTABLE, la �rauttF)MA SS P.st,ll) com _,,,fu �_....__.......� .._ o
Project #' 98160 E,
System
Proposeepc; To
Proposed Septic tes'
j ,• 1.) The location of the property lines and the
(Existing Pits To Be Abandoned) I existing dwellrr g was obtained from a plan entitled
I I i Plot Plan of Land Located At 215 Sea View Avenue
Osierville, MA prepared-by Yankee Survey
I ( Consultants on August 24, 2000.
1 10'Min. I II by
2 Sullivan Engineeringlocated on.September ivan 16, 2004.
3.) All other topography was obtained- from
the Town of Barnstable G.I.S.
TH-1 -
N
i 'Min. I ' O
o
4.) The datum used is NGVD '29, a fixed mean
sea level datum.
5.) The Intent of this plan Is for the permitting
T I I of the.septic upgrade only, and is only valid
j l with an original stamp and signature.
O 102
O 1Syv 1
W .O 0 -
Min I
N i1
- o OF
l U PETER
o E�isting
' CIVIL
6 - Bedroom
" Dwelling
12' 10'Min. 4(Cape C 'd Basement)
� .
ZONE:
�...--�
W '
Area (min.) 87,120 SF
_ `-
! Frontage (min) 20' n
I Width in) 125' � ,
10'Min. - k �
I Setbac s:
Fron t 30'
►I I I Side 15' 1 • r
Rear 15'
I .
a
OVERLAY DISTRICT: rc°
I
Q AP - Aquifer Protection District fo (�S
o _ As Shown on Plan Entitled o r`
W ►v Lot Size 0.56 Acres "Revised Groundwater Protection ' o?
W' '� j i I Overlay Districts" - April, 1993
FLOOD ZONE LOCATION MA
i
F L P:
Community(El.
,No._C = e: _ '
Scal 1 2000
#2s000 ools D ASSESSORS REF.:
Jul 2, 1992 Map .138, Parcel 017
Revision: Relocated S.A.S. 09 20 04 R
Title: SITE PLAN Prepared By: Prepared For: Date: - May 12, 2004 m
PROPOSED SEP71C UPGRADE Sullivan Engineering, Inc. Priscilla D. Berrngrath =°
AT PO Box 659 215 Sea View Avenue• Scale. 1, = 20"
215 SEA VIEW AVENUE osterville, MA 02655 o
Osterville, MA.' 02655
(508)428-3344
BARNSTABLE, (OSTERMLE) MASS PSWIPEAbolcomfax Project #t 98160 N