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I 347 Sea View Ave ] Page 1 of 1 .
Miorandi, Donna �l
From: John Odea [John@sullivanengin.com]
Sent: Monday, April 11, 2011 12:43 PM
To:' . Miorandi, Donna
Cc: 'Matthew Falconeiri'
Subject: RE: 347 Sea View Ave
Donna,
As a follow up to our discussion today, and a previous discussion in January, we have been reviewing
the information,available on the existing septic systems, the existing dwellings,and the proposed
modifications to the dwellings.
Although the design number of bedrooms and the actual number of bedrooms for the,main house has
been listed as 3—the two existing 1,000 gallon leach pits have capacity for at least 6 bedrooms.
Although the design number of bedrooms and the actual number of bedrooms for the guest house has
been listed as 1 —the existing 1,000 gallon leach pit has capacity for at least 3 bedrooms.
Since the systems have passed inspection, and since the work proposed is not intended to exceed the
capacity of the existing systems we believe the Title 5 requirements have been met.
John O'Dea, PE
Sullivan Engineering, Inc.
(If you have a chance—please confirm that this meets your needs, so I can save the contractor a trip
tomorrow if there is an issue)
From: Miorandi, Donna [ma i Ito:Donna.Miorandi@town.barnstable.ma.us]
Sent: Monday, April 11, 2011 10:26 AM ,
To: john@sullivanengin.com
Subject: 347 Sea View Ave
Hi John, Had a builder inhere this morning for building permits on this property. The septic for the main
house only shows that it is good for 3 bedrooms. We need one that states it is good for 4 (four) bedrooms
and the guest house states that it is only good for one bedroom and it should be'good enough for three
(3). The builder will get me floor plans for the guest house.
The main house would be an increase in flow from a 3 to a 4 bedroom. Call or e-mail me back on this.
Feel bad builder had to go back off Cape today and then perhaps come back again tomorrow.
Donna Miorandi
4711/2011
c � . Z n IV WTOWN OF BARNSTABLEMA�� VA �
UNDERGROUND � AND CHEMICAL STORAGE SYSTEMS' I-r n
ASSESSORS MAP NO. PARCEL NO. (�
ADDRESS:,�� S V VILLAGE: VIII-e '
NAME ����_��._ �`f l� L([ta,r\
CONTACT PERSONS �� L�,t.,Q-� PHONE NUMBERc��--
LOCATION OF TANKS:. - CAPACITY: TYPE- OF' FUEL. AGE: TYPE: LEAK
OR CHEMICAL'* -
{� DETECTION
-- D ec/,�� —� �d�. __ f. _ -_ _ i �_. SYSTEM!
i
DATE OF PURCHASE OF EACH: 1. ? 2. 3. 4. 5.
DATE OF FIRE DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS
fil&hly a-6� - 1�9. 2
'LEASE PROVIDE A SKETCH SHOWING THE LOCATION OF TANKS ON THE BACK OF THIS CARD. Qn
�JY
1
w
Ho v s� S yrs o l d
`! Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
347 Seaview Ave-Guest House
Property Address
Travis Rhodes & Rachel Creutz
Owner Owner's Name
information is Osterville MA 02655 1/25/11
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 se ss checklist at the end of the form.
Important:When general Information
filling out forms .�
on the compu r,
use only t tab 1. Inspector ~�
key to ve your
curso
r-do not Darren Michaelis
use key.e t e return Name of Inspector
;
Foresight Engineering Inc.
Company Name
88 West Grove Street Suite#2'
Company Address
Middleboro MA 02346
<TTe-le-hne
ity/Town State Zip Code
08-245-2148 S13595_
po Number License Number
B. Certificat'ran—'
I certify that I have personally inspected the sewage disposal system at this.address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
2/1/11
Inspector's Signature Date
The em inspector shall submit a copy of this inspection report to.the Approving Authority(Board
of ealth 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 coples 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.
l
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal ystem•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 347 Seaview Ave-Guest House
Property Address
Travis Rhodes & Rachel Creutz
Owner Owner's Name
information is required for every Osterville MA 02655 1/25/11
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cone.)
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:
All components were located and inspected.
13) 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.
Li Y ❑ N ❑ ND (Explain below):
t5ins•09/08 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
M 347 Seaview Ave-Guest House
Property Address
Travis Rhodes & Rachel Creutz
Owner Owner's Name
information is required for every Osterville MA 02655 1/25/11
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:
El 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
347 Seaview Ave-Guest House
Property Address
Travis Rhodes & Rachel Creutz
Owner Owner's Name
information is required for every Osterville MA 02655 1/25/11
page. CityfFown 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:
i
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
0 ® 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 Y2 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 347 Seaview Ave-Guest House
Property Address
Travis Rhodes & Rachel Creutz
Owner Owner's Name
information is required for every Osterville MA 02655 1/25/11
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure:
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ® the system is within 400 feet of a surface drinking water supply
❑ ® the system is within 200 feet of a tributary to a surface drinking water supply
0 ® the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone Il of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official' Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
347 Seaview Ave-Guest House
Property Address
Travis Rhodes & Rachel Creutz
Owner Owner's Name
information is Osterville MA 02655 1/25/11
required for 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
E ❑ 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?,
❑ E Has the system received normal flows in the previous two week period?
El ® Have large volumes of water,been introduced to the system recently.or as part of
this inspection?.
® 0 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?
E ❑ Was the site inspected for.signs of break out?'
® ❑ Were all system components, excluding the SAS, located on site?
Z El 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):' 1 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd.x#of bedrooms): 110
t5ins 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
�^ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments
wM 347 Seaview Ave-Guest House
Property Address
Travis Rhodes & Rachel Creutz
Owner
Owner's Name.
information is required for every Osterville MA 02655 1/25/11
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Single Bedroom Guest House
v
Number of current residents:, 0
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 g (9p ))� .
Detail:
Sump pump? _ ❑ Yes E No
Last date of occupancy: Summer Home Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR'15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap.present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.7 of 17
Commonwealth of Massachusetts
1 . Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 347 Seaview Ave-Guest House
Property Address
Travis Rhodes & Rachel Creutz
Owner Owner's Name
information is required for every Osterville MA 02655 1/25/11
page. Cityfrown 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: None Available- Pumped in 2005 as part of inspection
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared,system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval
❑ Other(describe):
t5ins•09/08 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
347 Seaview Ave-Guest House
Property Address
Travis Rhodes& Rachel Creutz
Owner Owner's Name
information is required for every Osterville MA 02655 1/25/11
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:
Unknown
Were sewage.odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.5feet
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.):
no evidence of leakage, proper venting provided
Septic Tank(locate on site plan):
Depth below grade: 2
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
1000 gallons
Dimensions:
Sludge depth: 0il
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
w 347 Seaview Ave-Guest House
Property Address
Travis Rhodes & Rachel Creutz
Owner Owner's Name
information is required for every Osterville MA 02655 1/25/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information cont.
Y (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
011
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? Field.Stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Cast Iron cover at grade in stone driveway, Concrete baffles in place and functioning properly, no
evidence of leakage or backup, normal liquid levels witnessed.
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 the 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
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 347 Seaview Ave-Guest House
Property Address
Travis Rhodes& Rachel Creutz
Owner Owner's Name
information is required for every Osterville MA 02655 1/25/11
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time
of Inspection) (locate on site plan):
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
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 347 Seaview Ave-Guest House
Property Address
Travis Rhodes & Rachel Creutz
Owner Owner's Name
information is required for every Osterville MA 02655 1/25/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No Dbox
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•09/68 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 347 Seaview Ave-Guest House
Property Address
Travis Rhodes & Rachel CreutZ
Owner Owner's Name
information is Osterville MA - 02655 1/25/11
required for every _
page. City/Town State Zip Code Date of Inspection
D. System, Information (cont.)
Type: .,
® leaching pits number: (1)6'x6
❑ leaching chambers number:
❑ leaching galleries number:
❑, leaching trenches ..number, length:
❑ leaching fields number,dimensions:
El overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of-soil, signs of hydraulic failure, level ofponding, damp soil, condition of
vegetation, etc.):
cast iron cover just below stone driveway and mulch bed,no scum or solids carryover, pit is dry with
highwater mark approximately,10"from bottom of pit. no'evidence'of.groundwater. Pits are the type
of system that can last for longer-than expected if maintained with annual or biannual pumping.
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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments.
,M 347 Seaview Ave-Guest House
Property Address
Travis Rhodes & Rachel Creutz
Owner Owner's Name
information is required for every Osterville MA 02655 1/25/11
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.):
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•09108 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 347 Seaview Ave-Guest House
Property Address
Travis Rhodes& Rachel Creutz
Owner Owner's Name
information is required for every Osteryille MA 02655 1/25/11
page. City/Town 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:
r
t5ins+09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17'
Commonwealth of Massachusetts
H . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
347 Seaview Ave-Guest House
Property Address
Travis Rhodes& Rachel Creutz
Owner Owner's Name
information is required for every Osteryille MA 02655 1/25/11
page. Cityfrown 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: 11
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: 9/12/03
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:
A percolation test was performed on 9/12/03 with groundwater determined to be 11' below grade.
The bottom of the leach pit is 8' below grade with no evidence of groundwater inflow. The system is
not within the water table and meets all minimum separtion requirements.
I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 347 Seaview Ave-Guest House
Property Address
Travis Rhodes& Rachel Creutz
Owner Owner's Name
information is required for every Osterville MA 02655 1/25/11
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
TOWN OF BARNSTABLE
6ve,sT' House—
w LOU �� SCaq VlGW /-�Ve. SEWAGE #
VILLAGE U 'V 1 I ASSESSOR'S MAP & LOT 13 El- 003 {
INSTALLER'S NAME&PHONE.NO.
/a--
SEPTIC TANK CAPACITY U(It3
LEACHING FACILITY: (type) w k PiT (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist !
within 300 feet of leach;ng facility Feet
Furnished by J
—r
Pp
6A
f
30
ass �a
a.$ 3 8
a
i
:f
FP
4
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 347 Sea View Avenue(Guest House)
Osterville,MA 02655 "
Owner's Name: Bob Breault � �
Owner's Address:
93
Date of Inspection: September 29, 2006
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400 '
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the i tion reporte
below is true, accurate and complete as of the time of the inspection. The inspection was perfon "ilk`based ot> y .U!
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a MP.
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste
Cn
Passes
Conditionally Passes
Needs urther Evaluation by the Local Approving Authority
Fails "
Inspector's Signature: Date: October 2. 2006
The system inspector shal\sub t 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.
Notes and Continents
**"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.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 347 Sea View Avenue(Guest)
Osterville, MA
Owner: Bob Breault
Date of Inspection: September 29, 2006
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 Conditiona
lly ally 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.
Answer yes,no or not determined(Y,N,ND)in the 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 347 Sea View Avenue(Guest)
Osterville, MA
Owner: Bob Breault
Date of Inspection: September 29. 2006
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to detennine 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
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 colifonn
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address'. 347 Sea View Avenue(Guest)
Osterville. MA
Owner: Bob Breault
Date of Inspection: September 29, 2006
D. System Failure Criteria applicable to all systems:
You must indicate either"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
✓ 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility 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.]
No (Yes/No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gPd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
4
f
y Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFAC
E SEWAG
E DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 347 Sea View Avenue(Guest)
Osterville. MA
Owner: Bob Breault
Date of Inspection: September 29 2006
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
I
Yes No
✓ — Pumping information was provided by the owner,occupant, of 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:
Yes No
✓ 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(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 347 Sea View Avenue(Guest)
Osterville, MA
Owner: Bob Breault
Date of Inspection: September 29 2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): I
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110
Number of current residents: 0
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):.
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped in 2005 for maintenance-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped detennined?
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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Date of installation unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 1 i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 347 Sea View Avenue(Guest)
Osterville MA
Owner: Bob Breault
Date of Inspection: September 29 2006
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grader 6"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal. (H-20)
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 101,
How were dimensions determined: Measuring stick
Conunents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.).
Tees were Present. The li uid level was even with the outlet invert. There did not appear to be any si ha of leaka e.
A steel outlet cover was to juade.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments (on pumping recommmendations, inlet and outlet tee or baffle'condition,structural integrity,liquid levels
as related to outlet invert, evidence of leakage, etc.).
7
Page 8 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 347 Sea View Avenue(Guest)
Osterville MA
Owner: Bob Breault
Date of Inspection: September 29, 2006
TIGHT or HOLDING TANK: None (tank iriust 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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: None (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: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 347 Sea View Avenue(Guest)
Osterville MA
Owner: Bob Breault
Date of Inspection: Sentember 29 2006
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1-6'x 6'(1000 gal)H-20
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.):
The it was dr . The scum line was approximately6"up rout the bottom. There did not appear to be any si ns of failure. A steel cover was
to zrade.
CESSPOOLS: None (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 or no):
Commments (note condition of soil,signs of hydraulic failure, level.of ponding, condition of vegetation,etc.):
PRIVY: None (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.):
9
Page 10 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 347 Sea View Avenue(Guest)
Osterville. MA
Owner: Bob Breault
Date of Inspection: September 29 2006
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
3 0
c
a /S 3a
W
3 a� 3g
3
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 347 Sea View Avenue(Guest)
Osterville, MA
Owner: Bob Breault
Date of Inspection: September 29, 2006
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 11 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:.
✓ 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:
A verc test was done on September 12, 2003 and water was located at]] below grade
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,
relating to the septic system, the inspection, this report andlor any components of the septic system which have not.
been located and inspected.
11
., COMMONWEALTH OF MASSACHUSETTS
EXEC UTIVE..OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROT TIOI
�l C. d•
TITLE 5
OFFICIAL INSPECTION-FORM-NOT FOR VOLUNTARY ASS SSMTS
/ g SUBSURFACE SEWAGE DISPOSAL SYSTEM FO
PART A
CERTIFICATION
Property Address: 347 Seaview Ave —Guest House
Osterville MA 02655 ,
Owner's Name: Bob Breault "
Owner's Address:
Date of Inspection: October S 2005 d
Name of Inspector: (Please Print) James M. Ford
Company Name: James M.Ford
Mailing Address: P.O.Box 49
Osterville.MA 02655-0049
Telephone Number: (508)862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal'system at this address and that the information reported
below is true,accurate and complete as of the time of 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
4this
er Evaluation by the Local Approving Authority
Inspector's Signature: Date: October 26, 2005
The system inspector shall sub on 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.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
r
Page 2 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 347 Seaview Ave. -Guest House
Osterville MA
Owner: Bob Breault
Date of Inspection: October 5 2005
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.
Answer yes,no or not detennined(Y,N,ND)in the 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
2
Page 3 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 347 Seaview Ave. -Guest House
Osterville MA
Owner: Bob Breault
Date of Inspection: October S 2005
C. Further Evaluation is Required by the Board of Healthy
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
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 and volatile organic compounds indicates that the well is free from pollution from that facility 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:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A-
CERTIFICATION (continued).
Property Address: 347 Seaview Ave. -Guest House
Osterville MA
Owner: Bob Breault
Date of Inspection: October S 2005
D. System Failure Criteria applicable to all systems: '
You must indicate either"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
✓ 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 waterelevation.,
✓ Any portion of cesspool or privy'is within 100 feet of a surface water supply or tributary t-o 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 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility 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.]
No (Yes/No)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 System:To be considered a large system the system must serve a facility with a design flow'of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply, i
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. ,
° 4
Page 5 of 11 -
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 347 Seaview Ave. -Guest House
Osterville MA
Owner: Bob Breault
Date of Inspection: October S 2005
Check if the following have been done: You must indicate" es"or"no"as to each of the following:
Yes No s
✓ 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 .P Y (SAS) the site has been determined based on:
Yes No
✓ 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(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 347 Seaview Ave..-Guest House
Osterville MA
Owner: Bob Breault
Date of Inspection: October 5 2005
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): n/a Number of bedrooms(actual): I
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110
Number of current residents: 0
Does residence have a garbage grinder(yes or no): No.
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown(Quest house)
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: The tanks for the main house&Quest house were dumped after the inspection for maintenance
Was system pumped as part of the inspection(yes or no): 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
f
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 347 Seaview Ave. -Guest House
Osterville MA
Owner: Bob Breault
Date of Inspection: October S 2005
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _4o PVC _other(explain):
Distance from private water supply well or suction line.
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 6"
Material of construction: ✓ concrete _metal —fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal. H--20(upgraded to H-20 by owner)
Sludge depth: I"
Distance from top of sludge to bottom of outlet tee or baffle: 31
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: -Measu`rinQ stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were resent. The liquid level was even with the outlet invert. The septic tank was made H-20 b addin 6"o concrete and
rebar to the top of the tank by the owner(see letter from engineer) There did not appear to be anLsi ns of leakage Steel cover
to zrade.
GREASE TRAP:. None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or.baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
r ,
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 347 Seaview Ave. -Guest House
Osterville MA
Owner: Bob Breault
Date of Inspection: October 5 2005
TIGHT or HOLDING TANK: None (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: allons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: None (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: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 347 Seaview Ave. -Guest House
Osterville MA
Owner: Bob Breault
Date of Inspection: October 5 2005
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: _1 -6'x 6'(1000 Qal)H-20
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.):
The Pit was dry. The scum line was a rox. 6"up from the bottom. There did not a ear to be an si ns o ailure. The pitwas
made H-20 bv the owner by adding 6"of concrete and rebar see letter rom en ineer. The bottom to rode was 7.5'. Steel cover
to zrade.
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition'of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Continents(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9
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Page 10 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE
SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: .347 Seaview Ave. _Guest House
Osterville MA
Owner: Bob Breault
Date of Inspection: October S 2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
ben 1.chmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
30
Will
C
3ag38
3
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10
f
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 347 Seaview Ave. -Guest House
Osterville HA
Owner: Bob Brea ult
Date of Inspection: October 5 2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 11 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
✓ 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:
A verc test was done on September 12 2003 and water was found at I P below 7,rade.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report.
- 11 '
SULLIVAN ENGINEERING INC.
7 PARKER ROAD/P O BOX 659
OSTERVILLE, MA 02655
Peter Sullivan P. E. Mass Registration No. 29733
psullpe@aol.com
phone 508-428-3344 fax 508-428-3115
October 14, 2005
James M. Ford
P O Box 49
Osterville, MA 02655
RE: 347 Sea View Avenue, Osterville
Dear Jim,
Mr. Breault has made improvements to the septic system at the above referenced property.
The septic tank and leach pit have been upgraded from H-10 to H-20.
I trust this meets your present needs.
truly yours
Peter Sullivan
Sullivan Engineering Inc.
Cc: Robert Breault
. I
No...... . Fmm..02.,..`.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD40F HEA
OF.... . . .. . .. .... ............. .....................
Appliration for Uisvuoa1 Works Tonstrnrtion Vrrm t
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage. Disposal
System at, Y '� c' � � �-J 0
y
Location Address 'r or Lot No.
Cl- waer Address
W
Installer Address
d Type of Building-,- Size Lot----------------------------Sq. feet
U Dwelling—No.' of Bedrooms_________ ________- ...........Expansion Attic ( ) Garbage Grinder ( )
P-4-, Other—Type-of Building ............................ No. of persons-_------_--___-__________- Showers ( ) — Cafeteria ( )
Pk Other fixtures ..__.._
d -----------
W Design Flow........................ gallons per person per day. Total daily flow....................... _._____ ----gallons.
WSeptic TankZLiquid capacity__ ____.gallons Length________________ Width...........----- Diameter---------------- Depth________..__.'..
xDisposal Trench—No..................... Width..............._._.. Total Length............_....._. Total leaching area ........sq. ft.
Seepage Pit N �.:.__._._.__ Diameter./..(� ___ Depth below inlet._----------. Total leaching area. d_.�__sq.-ft.-
.z Other Distribution box ( ) Dosing tank ( �)
a Percolation Test Results Performed by--------- _______________ ____ __............._. Date---------------------------------------- �.
Test Pit No. 1................minutes per inch Depth of Test t�
i Depth to ground water._--_____-_-___-___-----
G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__-___-____-____•--__--.
O Description of Soil--------
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
----•-------•-••-------•----•-•--------------------------•--------•-•-------------------------.--------•-----•----------------------------------••-----•-----------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code.—' The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signe -- -----• .-•----------•------•----...•-•----•---------•------••-••----------
--------------------------------
Date
Application Approved BY-...--- --•- ---- -------------- '� 7 3
Date
Application Disapproved for the following reasons:.........................--•- --------•------------•-------------------------------------------_---
---------------------•---•--------------•----•-•--•--=---•--•------------------•----...-•-..............-----------------------------------------------------------------------------------------------
i.� Date
PermitNo......................................................... Issued........................................................
Date
f No...... Fps.
THE COMMONWEALTH OF MASSACHUSETTS
'BOARD E HEALTH
.............OF... .:
App irafion for Disposal 19orks Cnuustrur$iuu ramit
Application is hereby made for.a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal
System at:
Location;Address or Lot No.
� � I
' .............•-------- • ................................
i
caner Address
W f'
--------------------------........................................................................ --•-----•.--•----•----.._....-----•-----------._...---....----------------•---••••-----•-----•••--
Installer Address
d Type of Building p,� Size Lot----------------------------Sq. feet
U Dwelling--No. of Bedrooms________ ......... '_____>...........Expansion Attic ( ) Garbage Grinder
Other—. Type of Building _______________ p ( ) ( )p-, _____________ No. of ersons..____._______________._____ Showers —Cafeteria ,
f4 Other fixtures ......................................................
W Design Flow.......................... ......gallons per person per day. Total daily flow...................... , `;f'_gallons.
WSeptic TankZ Liquid capacity/ allons Length................ Width._._______...___ Diameter_------------- Depth...___.__._.._..
x Disposal Trench—No_____________________ Width___.................... Total Length.................... leaching area--------------------sq. ft.
Seepage Pit.Now" ____________ Diameter./--`"�"�__ Depth below inlet-/...__________. Total leaching-area. _�...sq. ft.
Z Other"Distribution box { ) Dosing tank ( )
Percolation Test Results Performed by.____-__--_________________` JDate_.____________________.__._._.______.
W -------------
,� Test Pit No. 1................minutes per inch Depth of Test `it____________.____.. Depth to ground water-.---:_--.--_--__.
f=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wafer---________-:____-__---.
ODescription of Soil .....................................................---------------------------------------------------------------------
x4
V ----•---•----•----•----•-•••--••-•--••••-----------------------•••............------•---•••-•--•••--•-•---••--•---•---•-••-•••-----•••-----------------••-•-•------•-••------------•---•-••-----------
W
VNature of Repairs or Alterations—Answer when applicable.--____________________________________________________________________________________________-
-------------------------------------------------------------------------------------------- -------------•--------------..------------------------------....•.---------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued,by the board of health.
Signed,7 ,, -••-------•-•----- ----•--------•-•--•--•--•---------•• ................................
4 ✓ Date
Application Approved By.__ �� cif -----------------
r
Application Disapproved for the following reasons:.............................../-------------------------•---••--•------------------•-----•-------------------
----------------------------•-------------•-•-----•---•-•--------•-•------•-••-----------................................................-------------------------------------------------------------
Date
Permit No..............•••--•••---•...............••-•---._:..__. Issued..!--. ----- -- -- --•- -----•
ate
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r _
.................OF...... ga, x' uy ... ,;;r.s n o ..............
elrrtif rate of Tamp aurr
"THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (/) or Repaired ( )
i
bY -----•--••••.... •••---••••_•••-...----------------•-----------•------.---------K- ------................................................
Installer,,,,,
at............................... a ------ �. a ' -` o ; �-
14
has been installed in accordance with the provisions of Article XI of The fate 5<tnitaCode as described in the
application for Disposal Works Construction Permit No.,______________ ___________ dated---- __ ___________
AN T
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRUED AS A GUAREE THAT THE
SYSTEM WILL FUNCTIObI SATISFACTORY.
r
DATE - �� ��.....---•------------------•------. Inspector - �__ _/ ---- 6 "I l- —
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
s
.-z = FEE__{ �a -'-----
- �i��ru,��al urk,� C�u��frur�iuu rr�i�
Permission"is'hereby granted s.................................................................................................................... ____________
to Construct or Repair ( ) an Indivldu Sewage Disposal S stem . l
p
ti Street
as shown on the application for Disposal Works Construction Permit No J� L/ t . Dated---- <_.•••--__
1
41 I � - o
= _ --" --•-
r Bar�of health 2"
DATE.......................................
FORM 1255 HOBBS & WARREN.,.INC., PUBLISHERS
Fireplace ........... ...................... .........................................Approximate Cost ..(�. T� .�o.�.........
-
Definitive Plan Approved by Planning Board ________________________________19________ . e-
6'
Diagram of 'Lot and Building with Dimensions
SUBJECT TO APPROVAL OF BOARD OF HEALTH �C9t -tb Q!t>. 6a
blA
LX6e.&,kw,:,Td
?01
SEPTIC SYSTEM MUST BE
kwb4'j �� . INSTALLED IN COMPLIANCE
t WITH ARTICLE II STATE-
SANITARY CODE AND TOWN
REGULATIONS._ �--
z/7/7-S
I, hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
-- _ construction: .
Name .J.. .0 .11-..70... . ........
Q
Town of Barnstable
Depat•tnlent of Ilcallh,Safely,and Environmental Services /
�1HEr Public Health Division Date_
367 Main Street,Ilyannis MA 02601
• BARNRUBLF -
MABB. -
f6J9
"lEorAri+A Datc Scheduled�z(Q '1'imc 10:30 Fee I'd. /OU—
Soil Suitability Assessment.for Sewage Disposal
Performed By: SLylkyln j Witnessed Il �...
LOCATION & GENERAL INI{OI m1A1ION
Location Address 347 5e0,Vifw Poentie Owner'sNamc
Os�rv�11Q
Address F.0-3ox -joy
Os�e<vl\Q
Assessor's Map/Parcel:
)3a'OZ 1 Engineer's Nmnc Pe{er SvlVwav\
NEW CONs—rim TION V REPAIR 5tl\�w0^ EA51nrcr.n,
telephone N ;i1g-yZ8-331J
Land Ilse tt
R2S�PnT�i1 Slopcs(%) C)-ZO/b Surface Stones NA
Distances from: Dod Water Open t r r
I y I50 It Possible Wet Area 150 � n Drinking Water Well _��(t
Drainage Way S r+ ft Property Line (ad ± It Other R
SKETCI I:(Street name,dimensions of lot,cxacl localions of lest holes&perc tests,locate wetlands in proximity to holes)
SEA vleW .,
z .....
y
-
TK- ;
1 f
Parent material(geologic)_C}J�I>t5� f�Gjn ± SEP a m
Dcplh to Bedrock 500
Depth to Gnnuldwalcr: Standing Water in Ilolc: Weeping from HE
1'it I;ncc /0 TOWS
ND NC' i -
r QLfN OI=F '11-3LC
Estimated Seasonal I ligh(iroun(hvatcr _EL. 1.0
1 ETL+;YMINA I`ION Vol SEASONAL ITIOII 'VVATE,lt'r'AI3L
Mclhod Used. .
_NONE- W17HIN 0' OF OPEN WgTEP,
Depth Observed standing in ohs.hole: Depth to soil mottles
Depth to Weeping front side of obs.hole: rtr'
in. Grounchvalcr Adjustment R.
Index Well N_ Rending Datc: - htdcx Wcll Icvcl Ad'.factor
I _ Adj.Groundwater Level
1'CItcOLA'I�ION'I`I��sT uoe 9�I Ion lirtte�o �o
Ilol
c ervation
tl /
Time at 9" :/0
Depth of Pcrc 3b� Time at at Ci'.
Start Pre-soak'time @
jo* Time(9"-G') _ m;
End Pre-soak 1/:D
Rate Min./Inch Z mrtl�rn
Site Suilnbilily Assessment: Site Passed �/ Site Failed:
Additional•I'csting Needed(Y/iJ) ,
i
Original: Public►►cahh I)ivision Obset•valion 1101e Data TO Ile Completed on (lack j
Copy: Applicant M
11 I'1(JN;ItI�Y.,L L(aG ll� lc # —
Depth from Soil I lorizon Soil Texture / -
Soil Color Soil other
Surface(in.) (USDA) Munsell
t ) Mollling (Slniclurc,Sloncs,nouldcres.
SAND 4SL��t�11sy�°Lo(Lravc�
MeD. 5Ar1D -- --
ZZ—`i I mom. sP.r,tp ---
y l
44
11+;E�' OBS {1ZVA'[ION DOLL+ >LOG I;t(ilc#
Depth from Soil Ilorizon Soil'I'exlure Soil Colur
Surface(in.) Soil Other
(USDA) (Munsell) Molding (Structure,Stones,Houldeics.
Consislcncv %Gra cl)
X)CUIC
Dcpth from Soil Ilorizon Soil'I'cxture Soil Color
Surface(in.) USDA Soil Other
( ) Mun sell
( ) Mollling (Structure,Stones,Uoulderes.
I i n %'ravel
llZ' OI3S (tVf1'1IC1N 1)<OL LOG [[u>c
Depth from Soil Ilorizon Soil'1'cxlurc
Surface(in.) Soil Color Soil Olhcr
(USDA) (Munsell) Mottling (Structure,Sloncs,l.fouldcres.
i
flood Llsurauc R•iln Mail.
Above 500 year flood boundary No ✓ Yes
Within 500 year boundary No_ Yes ✓
Within 100 year flood boundary No_ Yes ✓
Aeuth of Naturally pccurriup Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout(lie
area proposed for the soil absorption systcln7 _)K5
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on AjLCA 111L (date) I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by file consistent with
° the required t 'Ig,cxperti mieennce described in 310 CM15.017.
PS
Signature— I?ate
OARAOE PLAN5 / ELEVATION5 W
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MAKE NEW DOOR Z
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' ❑ ❑ ❑ - V - REMOVE EXIST.WINDOW REMOVE EXIST.WINDOW �M/�'� � S LWL��
5EGONO FLOOR PLAN
F I R 5 T FLOOR PLAN a
SCALE 1/8"=1'-0" U �
SCALE 1/4"=1'-O"
1 txB LEDAR LAP txe CEDAR LAP 1 1 1xB LEDAR LAP
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RED CEDAR SHINGLES ON CEDAR BREATHERS t - Q i.
{ RED CEDAR SHINGLES ON LEDAR BREATHER5
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