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HomeMy WebLinkAbout0489 SEA VIEW AVENUE - Health 489 Seaview Aver," Osterville A= 138 — O 8 �I f , No. V v i► Fee ` THE COMMONWEALTH OF MASSACHUSErrs Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippliLation for Misposar 6pBtem ConstCULti01C'VPrmit Application for a Permit to Construct( ) Repair 0<) Upgrade(>0 Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 148 4 5 S9 v i t tv AVa Owner's Name,Address,an d Tel.No. S OTE2VILL�; M/�SS MI i-�At2Ri501✓/��c�1!_7HV Assessor's Map/Parcel 13 6 D28 L4 g tER 1/1 L/LE Installer's Name,Address,and Tel.No. M� fl )1 Designer's Name Address and Tel.�No.6-09-y 26—3 3 4 C R` SLi Lr: ►i/AN LNG i I'[�tT21 yc I/vc. Jnje� �fl$-36 o q �PlLKE2 2v. . Os7t2�, . �,�ss Type of Building: Dwelling No.of Bedrooms Lot Size ye �// A C- sq-ft Garbage Grinder(IIJP- Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 66© gpd Design flow provided g l,�8 gpd Plan Date 'TA N.. S� ZOO Number of sheets ( Revision Date Title SEa 7-1G S>/s7"E14 " C,rA D Size of Septic Tank 2 CvM Pt9 rjM&AIT 2..0od 646ype of S.A.S. VZ'A 9 S`L�AC`iili,yedll4l &Fr Description of Soil O S L� /Y/�4/�G/�/1//G-O- , .r �� �iC 2y D A fZiC. Fry`i S 14 131Z/V. 5,41VD if Loh -A r I'-' 3 L!"YES Isly saw. -Me P..s,4tilD laYjz ,5-A-0- f3— , 34 - t � L'77 1E� i s H 8 2 Ali M" S19-n/D `2-. .6- Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersignedU&E e construction and maintenance of the afore de -site sewage disposal system in accordance with the provihe E vironmenta Co o to place the system in operation until a Certificate of Compliance has been issuf He t . Date Application Approved by f 5 Date Application Disapproved by Date for the following reasons Permit No. ���1 �� Date Issued L/O��� 0 I »n.....- --.a.-swel...•o:M•i..r�•.:.,.,:..-�.�.—. ._.� v n ,. . .,.; .:+...,�. .. ,..,.�..r^-.,.S...r.{-�-—- -- ,ti - -s. ., —....,.. :4 — ;..j. .,:`4- - _. - - - - - No. i i _ �` � ' � Fee THE COMMONWEALTH OF MASSACHUSETTS` Entered in computer: y PUBLIC HEALTH DIVISION W TON'OF�BARNSTABLE,,.MASSACHUSETTS Yes ' x i " ��'' Yicatiom fog his osar pstem Construction 136mit Applica€ion.for a Permit to Constrict( ) "Repair�') Upgrade: Abandon'(, ) Complete System ❑Individual Components Location Address or Lot No.48 q S 6H V I G w AV I- Owner's Name,Address,and Tel.N . p,S'TE2V1L-LS7 -M Ss �yi NAR2tisoNmeC-AtYN� f 'Assessor's Map/Parcel 13 B d28 :. 1 �v�ts�✓0a /-;A Installer's Name,Address,and Tel.No. J rI on y �il 1{yt� Designer's Name Address and Tel No.5-09-q 2P 3 3 y y o SW�Lr!/��' L�/YG-Iv�c��lLirivj ItiK' r JUJc-c �l7Cl 36 - dY q -rp42KER 2D. ps7eF21//Ll.E /yf,�css Type of Building: Dwelling No.of Bedrooms Lot Size 'y 4// A G sq-ft i Garbage Grinder(lWi Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures !. Design Flow(min.required) _ $5C� gpd Design flow provided 5lo f3 gpd . Plan Date -TA M. 5 , ZOO!I Number of sheets I Revision Date t Title'5'EPIr/G S 1/S Al 61 Pig-r A D Ag- / F Size of Septic Tank 2 CaMPi4r7/11EA/T 2-0c7aG-, Lrype of S.A.S.('Z.'A 4 S-1 L:�AL j1V.-ieh,4d1;3E/— Description of Soil O— S " LlA/l?�O,QlrAN/G-O- �1t2-lOARX e_ry'1sM 13RA/ -541VQi f ' '40AA1 —A , 11'-- 3 y yEL I59 RJZW.. MEA spiv y '� 1 2G', D /�Y2 s�f— Q-- , � LT - YEL i s H Bad,- /Yl e-0 sA411) Z $�j Nature of Repairs or Alterations(Answer when applicable) ' -" Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore desc 'bed-on-site sewage disposal system in s accordance with the provisions of Title 5 of the E vironmental Co o to place the system in operation until a Certificate of 1 Compliance has been issued by this Board of He t . Signed Date a 9' / .f Application Approved by Le Date t Application Disapproved by Date ". for the following reasons ' ,, Permit No. �� Date Issued — w, , - ---------------- ------ - - ------------------------------------------------------------------- ------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded Abandoned( )by k` `at t-1$q $EA eW A✓E �s MI L� ,/YI//Sf has been constructed in accordance with the pro isions of Title 5 and the for Disposal System Construction Permit No. dated Installer �.t i/}� Designer SULLIl�i9/1/L A/(r// 'ETL1/t��r //j/G #bedrooms �'r Approved design flo� 'S � gpd The issuance of thisiipermit shall not be construed as,a guarantee that the system will fitttctioon/as designed. Date +" (► f 3 a J 0 1 Inspector1_/ L No. (31 co -. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction i9ermit Permission is hereby granted to Construct( ) Repair( ) Upgrade'* Abandon( ) System located at y S 9 $L J�1//C/,✓ �/'� E121�/L L t �S-s and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date �t- -�. f� L (� vt Approved by Q Y r tom=K f/(t1,/J V (�,trs ccA) TOWN OF BARNSTABLE LOCATION 09 , �/ �(J SEWAGE VILLAGE_0p on I/C ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) S ScV & q`(size) NO.OF BEDROOMS OWNER A l L PERMIT DATE: �� ' Z Cf COMPLIANCE DATE: ' Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 55� TOWN OF BARNSTABLE ,,_,LOCATION ! 0 A� U/Q� SEWAGE#���-J - �Cie VILLAGE CS tef �I ASSESSOR'S &PAR�`C�ELL INSTALLER'S NAME&PHONE NO. �� c \1�►�D SEPTIC TANK CAPACITY LEACHING FACILITY:(type) CCa4&044+b(size) �,�� ' S NO.OF BEDROOMS j OWNER M c CArf-11 PERMIT DATE: 1P- Z - D c/ COMPLIANCE DATE: 3� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well 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 ovCD A Cr _ ...�� cis C`e Will f ovie,,,TOWN OF BARNSTABLE _ LOCATION �� DQ — SEWAGE# - 75P VILLAGE —ASSESSOR'S MAP&PARCEL I NAME&PHONE NO.� Lk (3 0/hkt/ -'09-t W f SEPTIC TANK CAPACITY l���j��� 6>4<9 LEACHING FACILITY:(type) (size) 60y* NO. OF BEDROOMS- 1 OWNER. �l iA tLrgt-"hgs 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 leaching facility). feet FURNISHED BY + ;kS 4 Driveway F� 18 h Tennis Court s Town of Barnstable' Regulatory Services AM Thomas F. Geiler,Director, Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601. Office: 508-862-4644 Fax: 508-790-6304 Installer,&-Designer Certification Form- - --- --- - Date•�O\j 2� Zcc%�Sewage-Permit#-`\�---z Assessor's Map\Parcel----N -� �--- S' ��.��� av t.s Installer: . 5 F_� Designer: S �c— n Address: Address: � � On L uk;i�,c.aczD was issued a permit to install a (date) (installer) septic system at M59 See, E DS- c(-cbased on a design drawn by kic_ (address) L LA v PA,)&r.M ti dated 9- (designer) 1�I certify`that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced-above was installed with major changes (i.e.greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-bzjittctesigner to follow. R.TER Weti (Installer's_ ignatur_e :- SJILIVA114' No. 29733 is•r �® ® Al (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE.PUBLIC HEALTH DIVISION.CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.doc C) Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 489 Seaview Ave *Main House*_ Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 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. Important: A. General Information When filling out / forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name Q 189 Cammett Road Company Address Marstons Mills MA 02648 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 main enance of s"e sewage disposal systems. I am a DEP approved system inspector pursuant to Section 161340 of3* Title 5(310 CMR 15.000). The system: z .� ® Passes ❑ Conditionally Passes ❑ Fad&t ❑ Needs Further Evaluation by the Local Approving Authority ' stir •• cn: —t_ IM 00" December 2, 2008 In ector's SigInature 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. 08-289 R&M Part.MH•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 ` Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form Not for Voluntary Assessments ` 489 Seaview Ave *Main House* , Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont)_ Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® Lhave not found any information which indicates that any ofthe failure criteria described in 310 CMR•15.303 or in 310.CMR 15,304 exist. Any failure criteria not evaluated are indicated below. Comments: Cesspool pumped'as part of inspection overflow,pit shows no signs of surcharge. 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 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 ofHealth. *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: 4 !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 08-289 R&M Part.MH•08/06 Title 5 Official Inspection Form;'Subsurface Sewage Disposal System•Page 2 of 15 ' Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 489 Seaview Ave `Main House* Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 every page. CitylTown State Zip Code Date of Inspection _ f B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: h 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: y ❑ 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. 08-289 R&M Part.MH-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 489 Seaview Ave *Main House" Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at-a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or'cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_'day flow ® 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 groundwater elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 08-289 R&M Part.MH•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 489 Seaview Ave "Main House* Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 _ every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) . D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy.is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy,is less.than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.30.4; The system.owner should contact the appropriate regional office of the Department. 08-289 R&M Part.MH•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 f Commonwealth of Massachusetts V EMURN Title 5 Official Inspection Forrl Subsurface Sewage Disposal System Form - Not for Voluntary Assessments IS 489 Seaview Ave *Main House* Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 every page. CitylTown 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)] 08-289 R&M Part.MH-08l06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 489 Seaview Ave `Main House' Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 every page. CitylTown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 11 DESIGN flow based on 310 CMR 15.208(for example: 110 gpd x#of bedrooms): Unknown Number of current residents: Does residence have a garbage grinders ❑ 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 years usage (gpd)): Sump pump? ❑ Yes- ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 3.10 CMR 15.203): Ganons 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: Last date of occupancy/user Date Other(describe): 08-289 R&M Part.MH•08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .,, 489 Seaview Ave *Main House` Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Reason for pumping: Cesspool inspection. 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: 1920's Were sewage.odors detected when arriving at the site? ❑ Yes ® No 08-289 R&M Part.MH-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 489 Seaview Ave *Main House* Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: . .m Sludge depth: Distance from top of sludge to bottom of outlet tee or.baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 08-289 R&M Part.MH•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Seaview Ave *Main House* Property Address. R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 _ 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.): 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 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): 08-289 R&M Part.MH•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 489 Seaview Ave *Main House' Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08-289 R&M Part.MH•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 489 Seaview Ave *Main House' Property Address R&M Partnerships i Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool, number: One 6x6 pit ❑ innovative/alternative system y Type/name of technology: Comments (note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Overflow pit shows no signs of surcharge or hydraulic failure. 08-289 R&M Part.MH•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 489 Seaview Ave *Main House* Property Address R&M Partnerships Owner Owners Name information is required for Osterville MA 02655 December 2, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plari): Number and configuration One with overflow Depth—top of liquid to inlet invert 3' I Depth of solids layer 6 Depth of scum layer 3" Dimensions of cesspool 6x8 Materials of construction Block Indication of groundwater inflow ❑ Yes ` ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding,,condition of.vegetation, etc.): Cesspool is structurally sound, outlet tee is intact and clear. Cesspool was found approximately half full with a faint stain line at overflow pipe invert. 4 • 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.): t 08-289 R&M Part.MH•08106 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form I? Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .,, 489 Seaview Ave 'Main House' Property Address R&M Partnerships_ Owner - Owner's Name - ...----._—.._---- _---------------- information is December 2, 2008 D required for Osterville MA 02655--------...-------------..---._...------------.._. _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont) - 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. Driveway 18 Tennis Court • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,., 489 Seaview Ave 'Main House' Y Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells , Estimated depth to 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 USES database_explain: You must describe how you established the high groundwater elevation.- Bottom of cesspool is 8-10 feet higher than high tide mark at opposite side of property. 08-289 R&M Part.MH•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " 489 Seaview Ave *Carriage House* Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA . 02655 December 2,.2008 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 City/Town State Zip Code 508-428-1779 SI 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 ® Fails ❑ Needs Further Evaluation by the Local Approving Authority Vector --- December 2, 2008 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. 08-289 R&M Part.CH.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments 489 Seaview Ave *Carriage House* Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 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: ❑ 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 he not evaluated are indicated below. Comments: t 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 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 08-289 R&M Part.CH.doc•08/06 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments wM 489 Seaview Ave `Carriage House' Property Address R&M Partnerships Owner Owners Name information is required for Osterville _ MA 02655 December 2, 2008. every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: 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 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. i ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 08-289 R&M Part.CH.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 489 Seaview Ave *Carriage House* Property Address R&M Partnerships Owner Owner's Name information is required for Osterville _MA 02655 December 2,2008 every page. City/Town State Zip Code . ' Date of Inspection B. Certification (cont.) q , C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded orclogged 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 cesspooHs 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 water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 08-289 R&M Part.CH.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,. 489 Seaview Ave `Carriage House' Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December-2, 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑- ❑ the system is within 200 feet of a tributary to a surface drinking water,supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system'considered'a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should.contact the appropriate regional office of the Department. 08-289 R&M Part.CH.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5* Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 489 Seaview Ave *Carriage House* Property Address R&M Partnerships Owner Owners Name information is = required for Osterville MA 02655 December 2, 2008 every page. Cityr 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 backup? ® ❑ 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)] 08-289 R&M Part.CH.cloc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 489 Seaview Ave *Carriage House" Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 5 DESIGN flow based on 310 CM 15.203 (for example: 110 gpd x#of bedrooms): Unknown 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 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: F Unknown 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: Last date of occupancy/use: Date Other(describe): 08-289 R&M Part.CH.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 489 Seaview Ave "Carriage House` Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None 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) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1920's Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-289 R&M Part,CH.doc 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Comm onwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 489 Seaview Ave *Carriage House* Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2,2008 every page. Citylrown State Zip Code Date of Inspection D. System Information.(cont) Building Sewer(locate on site plan): 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: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------------------------------------ ----- Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 08-289 R&M Part.CH.doc•08/06 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 489 Seaview Ave *Carriage House` Property Address R&M Partnerships Owner Owner's Name information is required for Osterville MA 02655 December 2, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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, . 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): 08-289 R&M Part.CH.cloc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 489 Seaview Ave *Carriage House* Property Address R&M Partnerships Owner Owners Name _ information is �SterVllle required for MA 02655 December 2, 2008 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) - Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08-289 R&M Part.CH.doc-08/06 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 1 T of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form = Not for Voluntary Assessments 489 Seaview Ave 'Carriage House*. Property Address R&M Partnerships Owner Owners Name information is required for Osterville MA 02655 December 2, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type. ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 08-289 R&M Part.CH.doe•08/06 'Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection: Forme Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 489 Seaview Ave *Carriage House' Property Address R&M Partnerships Owner Owners Name information is �SterVllle required for MA 02655 December 2,2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped;as part of inspection) (locate on site plan): Number and configuration Two single cesspools Depth-top of liquid to inlet invert Depth of solids layer 0. Depth of scum layer 0" t Dimensions of cesspool 6x6 Materials of construction Block - Indication of groundwater inflow ❑ Yes ® No Comments (note'conditionof soil, signs'of hydraulic failure, level of ponding, condition of vegetation, etc,): Single cesspools fail per town standards. {. 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.): 08489 R&M Part.CH.doc•08106 Title 5 Official Inspection Form.Subsurface Sewage Disposal System Page 13 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form G r' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 489 Seaview Ave *Carriage House =° —--- .__:.............-- ----------- ._-_ ..:...._._.. -- ..._...------------ Property Address R&M Partnerships Owner — - -------..._.....-------------------------------- Owner's Name information is Osterville MA 02655 December 2, 2008 required for — every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. r 22 Carriage t House 50 46 52 i J r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 489 Seaview Ave `Carriage House' Property Address R&M Partnerships Owner Owners Name information is required for Osterville MA ' 02655 December 2, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ' ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: N/A 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: 08.289 R&M Part.CH.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 } w . . N cri ry RCc 4$q Spa Y►&.�.� ,�J I �b -�J �� i� _ .__--�__.._.___.�___ .1 �`i} - - .. ' �• _.._. _' �, `'� � D • e �" ..r•0 ':�'/ 'Y-.'.fir.'- " Q ,.. SEA VIEW AVENUE E.O.P ��L� t •.0 o4w s . , _ V SEA VIEW AVENUE a .._.. S 89045 "E 336.07° �16 GARC21Afr era ' / -- AOKI Houser -P _- — 1b o / \ M LOCUS PLAN --" s °t�,p- S'►pANK Scale: I 2000' / Assessor I Parcel 028 F-AtsT.i-r-ACH FIT-M 1 l A4flCYSP�D >"7C1ST�1�1G GAtZt21d�GE BLAeANDONeP t $ District Groundwater OverlayOVeriay - 7t?P Sat='r=ountcA-t'tON /�' � d' I P%PS'To-EX15-r: 3 0 -HOLIS1t SEWMAI Q R O pRIvEW�� N 89 045'45"W to AIN T.Fi.-2 w t�%i5T ip 7 _-�R" PROP. SEPTIC O 'Ti?r=Xt6T.. Sr 6 Sot\NFL 11 rAKtc. s�� o i Connect toExistinq House -TANK tvc;Cl o i�t Sewer.2 Locations,See 0 N o Partial Pion. See Note 4 M EG.18.t? (TYP) F.G.18.0 � r I � � I 14.25 Q Top E1.15.25 15 I ' 15.02 4' .27 '----------__ � Q� }, 14 of�• Bot.Ei.12.25 4�r .62 14.455 l } Qs 15's W/F s•.nx^ -.• �:: 5.15 I ' '�}c iST. L�a Gtii P1T ) p\N6k LL1iJG TUBS KEbf�>VDQN O N 2000 Gallon,2Compartment Bedding cis Bottom H.-I,E1.7.1 w H-20 Septic Tank Per Title 5 - No Groundwater.Groundwater at El.Less I Than 5.0 From TAB.,G.W.Contour Map. 1 DEVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM in\` � t� A 1 0 Not to Scale r\- .4t a Ar '0 PROP, NOTES TC7P.OGRL.P.N1C INt'ASiM/+."�ioN \ L Water Supply For This Lot is Municipal Water. Fr�onn -crow t.1 ot= �AIZNs fp g�� a, i 2.Location of Utilities Shown on This Plan Are Approx. s 1 \ At Least 72 Hours Prior to Any Excavation For This Project The Contractor Shall Make The Required 1 Notification to DIG SAFE-1-888-344-7233. PARTIAL PLAN 3.The Contractor is Required to Secure Appropriate Permits From Town Agencies For Construction Scale: 1 = 30 Defined by This Plan. 4 J'nstal l Risers as Required to Within 6 7of Finished Grade. NANTUCKET SOG�ND 5.All Structures Buried More ThanThree(3�)Feet or- Subject toVehicuivrTroffic istobe H-,20 Loading. 6.Septic System to.be Installed in Accordance With 310 CMR 15.00 Latest Revision And The Town of `t 4 .-i �1-• ��. i T.N.-a. It:4.ts.�- OVERALL SITE PLAN Barnstable Board of Health Regulations. p .Ali Piping to be Sch.40 PVC. Q t-CA'M, ovkoxt c O t_OJ�.NM1, OR"%Xc. Scale 1��= 100' 7.8.Depth of Inlet Tee Below Flow Line*- 10"Min. Depth of Outlet Tee Below Flow Line:.14"Min. �f;Y OAfiK GRAYIS'td 13ti1+t *IPa.A�Y pAt3K fslllA.V t.+�,.1rt.t3RN. , A "vADY LOAM 10Yt; AN 5.a l�►D`t .l.*AtA 1.01IR-S/1L With Gas Baffle. 9.Se ticTonk Shol I be a 2000 Gallon 2Com artments. YLSL'.t$Yl. 'i6iM t+AEsD 9A►li0 w/ t t gE►:15H pRN:Mt? sAtatQ W/ The First Compartment Shall Have o Volume of Not .. '$ M.W IF%so.5 10Yti SAD ,. � Fkv 1w ME:S '►CYi-5-/B p d LessThan1100Ga11onsAnd The Second.of Not Less `eG 314 l` Than 550 Gallons.The C m artments Shall be MisoLIr.VIFIV.i$H..['lR�t L.1- `/ L:1.$}t Ft1 M 4. p C SAND C McLl>.. S/►ND la.SY 4/4 Interconnected by Min 4 0 Vented inverted U-Shaped i 32 20 Pi eWithGasBaffle CL G t.ASS 1 M A-t- R 1 A►.l. t : AKS S,t t+.rSiAx-Mft% A%�. P t�a.c•s�icsvtatSwAr�R t-+tc G�'KQut t'ca 041 tits P6RG 0' 1�.�i,�l' Instoil a 4"0.Perforated PVC With Screwed S?A.TfG Cap,Inspection Port to Within'S"of Firished sti •tt :lea' -°-+rcaP. Grade DESIGN DATA t +�s95�-u�•.rr rn� f s�tcla t"ataotrt.G t�:A-t*c r C7.�W' ist:./s:� Finished Grade Carriage House-5 Bedrooms iRt4*I*4 rR No Garbage Grinder A !?Etxi ?t?tMt�R.tY `,T,.•C7`l7te.A s•1T `- c Compacted Fill Y 9P n a . bP Dail Fiow Ii0 x 5 =550 0 M Filter Fabric - -_ Use Septa 2 Comportment 20 O Gallon Septic m- c *` " wt'TMC $5.! b OESMAR/►1 ,t�5 TpCi gp1-t .-• yr Tank.See Note No.9. € a O 2";i/$'=1/2" LEACHING AREA _M o Leaching Pea Stone 550 d/0.74=744 s.f.Required. E. N Chamber .. .� 9P , w v 3/4 -11A Sidewalk 2(12+45)2 = 228s.f. .. Double Washed Bottom Area:12'x 45'= 540 s.f. 4-10 Store 768 s.f Provided LEACHING CHAMBER DESIGN All Pipes to be Schedule 40 PVC.Use 5 SITE PLAN CROSS SECTION OF CHAMBER -§oo gallon Leaching Chambers ina Not to Scale __. 12x45 Washed Stone Field as Shown. SEPTIC SYSTEM UPGRADE R. HARRISON MCCARTHY 489 SEA VIEW AVE. OSTERVI LLE , MASS. SCALE:AS SHOWN DATE: JAN. 5 , 2009 SULLIVAN ENGINEERING INC. OSTERVILLE, MASS. '� 0 2_3