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HomeMy WebLinkAbout0570 SEA VIEW AVENUE - Health s• 570 Sea View Avenue ' Oster aille A= 114 —067 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments t 570 Sea View Ave Property Address Robert Ritucci & Paula Madonna Owner Owner's Name information is required for every Oserville Ma 02655 9/1/20 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A.- Inspector Information Sly lN'43J4, on the computer, Michael DiBuono use only the tab key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Ln Co ,� Company Address Cotuit Ma 02635 City/Town State Zip Code 508-364-9587 S113522 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9/1/20 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 570 Sea View Ave Property Address Robert Ritucci & Paula Madonna Owner Owner's Name information is required for every Oserville Ma 02655 9/1/20 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is functioning as designed 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 570 Sea View Ave Property Address Robert Ritucci& Paula Madonna Owner Owner's Name information is required r every Oserville Ma 02655 9/1/20 fo page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9rlzi s 570 Sea View Ave Property Address l Robert Ritucci& Paula Madonna Owner Owner's Name information is required for every Oserville Ma 02655 9/1/20 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 t5insp.doc•rev.7/2612 0 1 8 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 f Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 570 Sea View Ave Property Address Robert Ritucci & Paula Madonna Owner Owner's Name information is required for every Oserville Ma 02655 9/1/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 570 Sea View Ave Property Address Robert Ritucci & Paula Madonna Owner Owner's Name information is required for every Oserville Ma 02655 9/1/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for.all inspections: 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,. 570 Sea View Ave Property Address Robert Ritucci& Paula Madonna Owner Owners Name information is required for every Oserville Ma 02655 9/1/20 page. CityrTown State Zip Code, Date of Inspection D. System Information 1. Residential Flow Conditions: ) Number of bedrooms (design): 5 Number of bedrooms(actual): 3 DESIGN flow based.on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Description: Number of current residents: Vacant Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): . 429 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form M1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 570 Sea View Ave Property Address Robert Ritucci& Paula Madonna Owner Owner's Name information is required for every Oserville Ma 02655 9/1/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: Source of information: Not Provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 facial Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 570 Sea View Ave Property Address Robert Ritucci& Paula Madonna Owner Owner's Name information is required for every Oserville Ma 02655 9/1/20 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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. i ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 4/18/01 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2.5 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.): System vents at the roof line t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 570 Sea View Ave Property Address Robert Ritucci & Paula Madonna Owner Owner's Name information a Oserville Ma 02655 9/1/20 required for every page. Cirylrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 411 Distance from bottom of scum to bottom of outlet tee or baffle 30" How were dimensions determined? Tape Measure/Data On File Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is recommended t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 570 Sea View Ave Property Address Robert Ritucci & Paula Madonna Owner Owner's Name information is Clserville Ma 02655 9/1/20 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) 7. 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.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts V Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 570 Sea View Ave Property Address Robert Ritucci& Paula Madonna Owner Owner's Name information is required for every Oserville Ma 02655 9/1/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): t5insp.doc-rev.7/26/2018 Title 5 official Inspection Form:-Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 570 Sea View Ave Property Address Robert Ritucci& Paula Madonna Owner Owner's Name information is required for every Oseryille Ma 02655 9/1/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form h i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 570 Sea View Ave Property Address Robert Ritucci& Paula Madonna Owner Owner's Name information is required for every Oserville Ma 02655 9/1/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No ponding or break out 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 570 Sea View Ave Property Address Robert Ritucci & Paula Madonna Owner Owner's Name information is required for every Oserville Ma 02655 9/1/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doo•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Assessing As-Built Cards https://www.townofbarnstable.us/Departments/Assessing/Property_... ' TOWN OF BARNSTABLE } LOCATION. SEWAGE# - VILLAGE 9157 �/1112 , , _- ASSES..SOR'&MAP;&LOT/I�'���..:• INSTALLER'S NAME&PHONE NO. rTOlr�7 I SEPTIC'TANK CAPACITY /S�d { LEACKNG.FACILITY:.(type) 00 6001 ,c./1,045 ;(s ie} yL xz NO.•OF BEDROOMS li I BUILDER OR OWNER.._ ._ GOty C OiLAv. PERMITDATE:. 3, Z_d lT 1 COMPLIANCE DATE: Separation Distance.Between the: Maximum Adjusted Groundwater Table and'Bottom of Leaching.Fac lity. :Feet: Private Water Supply Weli:and`Leaching Facility '(If any wells;ezist _ on;site or within 200 feet of leaching facility') Feet Edge U.Wetlaiid,and Leaching Facility(If any wetlands exist within 300 feerof leaching facility) Feel Furnished_by... 4 04 -� 47 • r, • GA�CC • ' 1J,g cK o f JJDvgE 1 of 1 9/1/2020, 10:15 AM Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 570 Sea View Ave Property Address Robert Ritucci & Paula Madonna Owner Owner's Name information is required for every Oserville Ma 02655 9/1/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 570 Sea View Ave Property Address Robert Ritucci& Paula Madonna Owner Owner's Name information is required for every Oserville Ma 02655 9/1/20 page. Cityrrown State - Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 3/20/01 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form q Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 570 Sea View Ave Property Address Robert Ritucci & Paula Madonna Owner Owner's Name information is required for every Oserville Ma 02655 9/1/20 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN OF BARNSTABLE LOCATION S-7 0 Seq v1 eW ✓ ye. SEWAGE # VILLAGE ASSESSOR'S MAP & LOT �j INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /UUb LEACHING FACILITY: (type) P tT (size) Cox 40 NO. OF BEDROOMS 3 BUILDER OR OWNER P 4n CILS (,:orC or► tl PERMITDATE: f �`~ COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility (If any wells exist on site or within 200 feel of leaching facility) ► - r Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Ulk PATIO , i r � 8 - y1 ' . . . ay TOWN OF BARNSTABLE LOCATION S 71J ✓ � SEWAGE # VILLAGE' �l�/�f ASSESSOR'S MAP & LOT /q—a INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY lS®@ LEACHING FACILITY: (type) Y 5A0 GAL cff*-macs (size) ,ir NO. OF BEDROOMS BUILDER OR OWNER/ GOty,4— gi AL, PERMITDATE: 3 l Z�!�1 COMPLIANCE-DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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) z Feet Furnished by -y C/8 , 04 -`� 447 y 3' a ,y r No. �C.fi Fee A4 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes � PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0ppYication for Miopogar 6potem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) [A/Complete System ❑Individual Components Location Address or Lot No. �y /� �.1 Owner'spNamF,Address and Tel.No. Assessor's Map/Parcel o o�j jG Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 7/-c7,3ZZ Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(/ [� Other Type of Building eS f 11C-eNo.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Z ® gallons per day. Calculated daily flow 3-31-0 gallons. Plan Date O Number of sheets / Revision Date Title s—.>© dam, Size of Septic Tank / ® Type of S.A.S. q Z X /Z mil'Z_ Description of Soil Nature of Repairs or Alterations(Answer when applicable) `le— ai,; Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by is Boar of He lth. Signed Date Application Approved by Date 3 Z Application Disapproved for the following reasons Permit No. 7" Date Issued 3Z Z ,7 No 'Fee .z CO V THE COMMONWEi�LTH'Of MASSACHUSETTS Entered in coinpute'r: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for �Migogaf *pgtem Construction Permit_ Application for a Permit to Construct( )Repair( )Upgrade(✓)Abandon( ) Exomplete System ❑Individual Components Location Address or Lot No. 5770 gzV Owner's Nam ,Address and Tel.No. UI�w`rr.� �D�� Assessor's Map/Parcel ©,j"v ill© Installer's Name,Ad�ess,and Tel.No. /( 4 Designer's Name,Address and Tel.No. 7 7/- 93 � 3621 Type of Building: Dwelling No.of Bedrooms Lot Size L sq. ft. Garbage Grinder( a Other Type of Building L�5- , ewrAo. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow //D gallons per day. Calculated daily flow SJ�� T rt gallons. Plan Date &Z9/ Number of sheets, / Revision Date /��6 Title 7 �. 5` �/�9/f'A�lp 4"/ 5-?� i5;v)411?et1 per. Size of Septic Tank �� , Type of S.A.S. qZX Description of Soil fil�`�P-- Gee w _ Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore deseribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed _ Date Application Approved by Date 3 Z Application Disapproved for the following reasons Permit No. 7.B a '� Date Issued 3 Z 7 o 7 i THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTINY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded Abandoned( )byDr at 51 -7 ��'PQ't e w O4.Ae has jbeen constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ��'�� f dated T — Z 7 0/ . Installer Designer The issuance of this he t shall not be construed as a guarantee that the syste fun c(ion designed Date l f Inspector _ 1 tEy No. LGy /- J'PS- ———— // Ir 04�7 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ioigpogal *patent Conotruction 3permit Permission is hereby granted to Conns!pctt )Repair( )Upgrade(Abandon( ) / System located at 0 ✓ �/�u-��� y✓ ry��l and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed leted within three years of the date of this pe t. Date: 3 �� Approved by —'� 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION v TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A ,� CERTIFICATION Property Address: #570 �� �'`� 4fq✓e ,F'O"(1574 /�40//¢ A26 e �/ a: OZ 55 to r a L'f�t4rr/���nq 7 Owner's Name: ►✓Aw �• Owner's Address: 2 So $��LtST y T 1L Date of Inspection: Name of Inspector:(please print) 45k2A19Ro �• CSiaN� Company Name: cS cSi1Q2 6 .,,cNC Mailing Address: U !7 L Z CG,3 Telephone Number: —9N5 - ,36 J— CERTIFICATION STATEMENT �, v I certify that I have personally inspected the sewage disposal system at this address and that the nformat6 rep4Red below is true,accurate and complete as of the time of the inspection. The inspection was perfo ed base84n mr training and experience in the proper function and maintenance of on site sewage disposal syste 'is. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Vpasses Conditlbnally Passes N ds urther Evaluation by the Local Approving Authority Fi 7 Inspector's Signatur Date: 5--6' y - 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. Notes and Comments �Yi ****This report only describ 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 p page 1 Pave 2 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 517611 Q&�a vl��j 41e 5 Zvi N Owner: /Y,0.0 — Date of Inspection: 6^-S— O-7 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D GA1 S��T,eam.' asses: 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: 770 A1141e, 'Pn oorz p/B. System Conditionally Passes: or more system components as described in the"Conditional Pass"section need to be replaced or repaired.Th . stem,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes, no or not rmined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and o r 20years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying s is tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is cturally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is a table. ND explain: Observation of sewage backup or break out or high static wate eve] in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. em 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 sys 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 1 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFIC(�ATION(continued) Property Address: f Vd CSC t/r6-k.J 5T'EQyr • Owner: Date of Inspection: 8-0 C. Further Evaluation is Required by the Board of Health: Co itions exist which require further evaluation by the Board of Health in order to determine if the system is failing to pr ect public health, safety or the environment. 1. System wil ass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not unctioning in a manner which will protect public health,safety and the environment: Cesspool or ivy is within 50 feet of a surface water Cesspool or pr vy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the B rd of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner at protects the public health,safety and environment: _ The system has a septic tank d soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a urface water supply. _ The system has a septic tank and S and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and th SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determ' a distance "This system passes if the well water analysis,perform at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the ell is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equ to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be atta ed 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: Owner: r✓c� Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No �ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool scharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or Xgged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or /cesspool •vlA✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow 7I4equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped —3 y portion of the SAS,cesspool or privy is below high ground water elevation. 4 ✓Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface 4/L��ater supply. y portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. aAny portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water -IV/q 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.] /YD (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. w/ E. a Systems: 9 To be con ' red a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate ei es"or"no"to each of the following: (The following criteria app arge systems in addition to the criteria above) yes no _ the system is within 400 feet of a sur drinking water supply _ the system is within 200 feet of a tributary to a s ace drinking water supply the system is located in a nitrogen sensitive area(Interim ellhead 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 s ' cant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large sys onsidered a significant threat under Section E or failed under Section D shall upgrade the system in accordance w 10 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: Owner: S$—O 7 Date of Inspection: /Yf1/.I9E�✓ Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes/No _✓ Pimping information was provided by the owner,occupant,or Board of Health ,//Were any of the system components pumped out in the previous two weeks? �/ the system received normal flows in the previous two week period? V H ve a 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 ? ''ar2UkC1Z The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes o fExisting information. For example,a plan at the Board of Health. y — Determined in the field(if any of the failure criteri related to Part C_ is at issue approximation of distance is unacceptable) [310 CMR 15302(3)(b)J 5 Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: V"/t� v� Owner: ¢,00 Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): S Number of bedrooms(actual): s DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ✓ `l �,�� Number of current residents: ,t/K vo�.r✓ Does residence have a garbage grinder(yes or no):� Is laundry on a separate sewage system(yes or no): ✓[if yes separate inspection required] Laundry system inspected(yes or no):__V/* Seasonal use: (yes or no):_ffS 1 Water meter readings, if availab a(last 2 years usage(gpd)): -'I�Nv;6P t#!%ey& Sump pump(yes or no):_ Z oob = � Cac. /n-y~n 4-e,',( -,,- Last date of occupancy:_,25#a Zew(p �6 91 .0 40 /Vf COM RCIAL(INDUSTRIAL 7,10 d.% Type of es ishment: �yf. Design flow(bas 10 CMR 15.203): gpd Basis of design flow(seats ns/sgft,etc.): Grease trap present(yes or no Industrial waste holding tank present(yes or Non-sanitary waste discharged to the Title 5 system or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: gv*J�L/(r &&r— -79n4Z 9/ir�e�/evAQe�. 4v e_ar4.ji X Was system pumped as part of a inspection(yes or no): Aldo /-V Ec.0 xr If yes, volume pumped: 4,-IA— allons--How was quantity pumped determined? k14, SIJ.I Reason for pumping: OA TYP F 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: IV iy1J Were sewage odors detected when arriving at the site(yes or no):� Yr` d_6uro + 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 51411cfVA11;el/ y✓r B Berri�// Owner: Date of Inspection: 6 d- 0�7 BUILDING SEWER(locate on site plan) Depth below grade: ♦8 « R.,Wzo A Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: /owvc�/g�� Comments(on condition of joints,venting evidence of leakage,etc.): r- (AIP 4.ts� 4 SEPTIC TANK:_+r(locate on site plan) o���� / �o� a �¢ h.vl we �6 co%✓ ( p e�cv�/A/ 4 Depth below grade: 30 ��� �,� o n k f L1-wy- l c%�-, «/e ffzwll Bs� Material of construction: concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:w s age confirmed by a Certificate of Compliance(yes or no)4/A(attach a copy of certificate) Dimensiony/'f(9 r/o=6"�G !/'� /SZ.t�fo�/�.rf/O e- Sludge depth: 2" 2 Distance from top of sludge to bottom of outlet tee or baffle: 3 Scum thickness: Distance from top of scum to top of outlet tee or baffle: t' Distance from bottom of scum to bottom of outlet tee or baffle: le~ How were dimensions determined: 66*wy Sep - Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc. / / Z��e/ �� Gbh Y.f 4W.L T-4 ml�W S t�G-f f/l�Ll dC � �I j�Y K� y� l I ! 'el c, &14 /e-�-/�`ap/c�e av�.`f-/ .P c �f'�sb�f�FY( —�'✓ �e���r�'Iop�.r�.��//Yl.;✓3cv�y/-s /V GRE TRAP:_(locate on site plan) Depth below grade: Material of construction:_c to_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, ctural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM MORMATION(continued) Property Address: Owner: sJd� Date of Inspection: TIGH HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) r4- Depth below grade: Material of construction: c ete , 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.): B N BOX "�(if esent must be o ened locate on siteplan) — DISTRI UTIO O p )( 3 3 cl 6 Depth of liquid level above outlet invert: Comments(note if box is level and distribution t9 outlets equal,any eve en/ce of solids carryover,any evidence of leakage into or out of box, etc.): /9�/v/ E i ST7iYF /l�°;�/�i''� }�r/Z'i tC�! l✓Pr�rP,rx� �O��t'�tiJ /a ra J-e 4// PU CHAMBER: (locate on site plan) 5"-Su Pumps in working order o Alarms in working order(yes or no): 6Or 71, 5;;¢J � r� Comments(note condition of pump chamber,con iti s and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: S�v '� vlea Usk v✓, / . Owner: stifa d�ti Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain w u✓ e T o e hest S oe � 4elrev�ci•� Type Beaching pits,number: in chambers,number: 52�0 y a,/ 1i 10 01aGa5 c Y.c�-e leaching galleries,number: f,¢s�lZ•��r ,a X ,v e�.�a!eP��/ leaching trenches,number, length: leaching fields,number,dimensions: �qt-a1e�Lzlvq 4'1 -Ze-rl'� e ,., ✓(J overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): �e,/ J+ �✓`t) CAlo v N� CE POOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configura ' Depth—top of liquid to inlet 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, ition of vegetation, etc.): PRIVY: locate o an) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, of ponding,condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: SAD 5f%-V�ew 8.,&,v,/lo Owner: /'hs .ate ` Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or ben arks. Locate all wells within 100 feet. Locate where public water supply enters the building. 3 J3 - L3 �v gr ate ,, C_ Vs' pav^i�� G d 4 w� `? 1316 �� SST moo B C n 10 I Page 11 of 11 z OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: S ?� cSC - !/ic-4/ 4✓c� , P_✓yi I Owner: rna --V Date of Inspection: SITE EXAM Slope l Surface water �;r.nQ Check cellar dYy / r Shallow wells 't7-a 5 �"✓ 4V 7 So✓✓tC.�•.� ;ire Estimated depth to ground water /S feet 4e CS /,7 @�� /7 z `�s Please indicate(check)all methods used to determine the high ground water elevation: V/Obtained from system design plans on record-If checked,date of design plan reviewed: 3��'O/` �or✓n erved site(abutting property/observation hole within 150 feet of SAS) Ql f/j o%/t-2- 3!3- dy ✓Checked with local Board of Health-explain: 'A.'.e'.' &4 Ch m ecked with local excavators,installers-(attach docuentation) Accessed USGS database-explain: '6� 01 �+ i2p �gr✓ �►✓ !/ o$ 0��,4,�j �jd� �G'g'✓ You must describe how you established the high ground water elevation: 14-:P c.2S�G'oy,G -jf Z e.*,2 Ijv4l 6-2—/,R'�?X — /Clv 4lo4w Zt/,9 rr�rf Ez/20 d�� �J �i 1.1 5. 9 e/e✓Z us�5 11 j y r 4: C TOWN OF BARNSTABLE i LOCATION 7� ✓eG�l�> G GL SEWAGE # 'ej i VILLAGE /�� /7/ C� ASSESSOR'S MAP & LOT/IV INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING'FACILITY: (type) Y Sao GAL C (size) i NO. OF BEDROOMS BUILDER OR OWNER GOh.e OA,4ti PERMITDATE: 3/Z :COMPLIANCE DATE: f//U I � TS Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 " 6-y y8 6-3 1 8' , q7 G. G�n �C COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET,BOSTON MA 02108 (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 570 Seaview Avenue, Osterville, MA Name of Owner: Frances Corcoran Address of Owner: Same Date of Inspection: October 30, 2000 Name of Inspector: (Please Print) .lames M.Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M. Ford Mailing Address: P.O. Box 49, Osterville, MA 02655-0049 Map: 114 Telephone Number: (508)862-9400 Parcel. 67 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ✓ Passes Conditionally Passes _ ''Needs Further Evalua'on By the Local Approving Authority � _ ails Inspector's Si ature: Date: November 1 2000 P The System Inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. NOTES AND CONRAENTS , p q No I/ 9 2000 V._ �'1 tit. {,+r •.t:... }t'"� �fi .. ;.y ? y,t. 4`'-�..+t.w:�c.�.ew'� revised 9/2/98 Page 1of11 Printed on Recycled Paper r° T SUBSURFACE SEWAGE DISPOSP :SEEM INSPECTION FORM PAN CERTIFICATV ontinued) Property Address: 570 Seaview Avenue, Osterville, MA Owner: Frances Corcoran - Date of Inspection: October 30, 2000 INSPECTION SUMMARY: Check A, B, C, or D. A. SYSTEM PASSES: ✓ I have not found any information which indicates that any of thr conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Condition., section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Bc .{ealth,will pass. Indicate yes, no,or not determined(Y,N,or ND). Describe basis of dear, �tion in all instances. If"not determined",explain why not. The septic tank is metal,unless the owner or operator h, -)vided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was insW, within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked, strucb w , uhsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if g; ��isting septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakoufor high static water level ; ed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. system will pas Health) s inspection if(with approval of the Board of broken pipe(s)are replaced obstruction is removed distribution box is levelled or replac The system required pumping more than four times a yc: clue 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 revised 9/2/98 Page 2oftl f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 570 Seaview Avenue, Ostemlle, MA Owner: Frances Corcoran Date of Inspection: October 30, 2000 ` r t; ,L`.•,let-4 , :,f�.s9niF .,�t: C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to'determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2)- . SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND,PUBLIC WATER SUPPLIER,IF.ANY)DETERMINES .-THAT THE SYSTEM ISFUNCTIONING`IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: . The system has a septic tank and soil absorption syistem(SAS)and the SAS is within 100 feet to a surface water supply or r .. a � r 1 r i ;9x! � ,,�}. c �:.. i^ "w =tributary to a surface water supply: v=r vet The system has a septic tank and soil absorption`system and the SAS is within`a Zone fof a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a.septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well,water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approidmation not valid). 3) OTHER revised 9/2/98 Page 3of11 r , r, S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 570 Seaview Avenue, Osterville, AM Owner: Frances Corcoran Date of Inspection: October 30, 2000 , D. SYSTEM FAILS: You must indicate either"Yes" or "No"as to each of the following: _ I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or 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 1/2 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public . health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone Il of a public water supply well The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 _ SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 570 Seaview Avenue, Osterville, MA Owner: Frances Corcoran Date of Inspection: October 30, 2000 ... _ .. � ..ram i �. r• .. � � .:.�. ,S.t ... :) .. Check if the following'have been done: You must indicate either.,"Yes or;;No as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health. ✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. n/a .As built plans havebeen obtained and examined. ,Note if they are-not available with N/A. , ✓ _ The facility or dwelling was inspected for signs of sewage back-up. ✓ _ The system does not receive non-sanitary or industrial waste flow. ✓ _ The site was inspected for signs of breakout. ✓ _ All system components,excluding the Soil Absorption System,have been located on the site. ✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions of baffles or tees, material of construction,dimensions,depth of liquid,depth of,sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on -— - -- ✓ Existing information. For example,Plan at B.O.H. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)l• ✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. .. a ,..;.t ...1i i ., 1 e '3F:��. . `4 jt t. ax••:s::� revised 9/2/98 Page 5of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART C SYSTEM INFORMATION Property Address: 570 Seaview Avenue, Osterville, AM Owner: Frances Corcoran Date of Inspection: October 30, 2000 FLOW CONDITIONS RESIDENTIAL: Design flow: 110 g.p.d./bedroom. Number of bedrooms(design): n/a Number of bedrooms(actual): 3 Total DESIGN flow n/a Number of current residents: 1 Garbage grinder(yes or no): Yes Laundry(separate 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 two year's usage(gpd): 1999-172,000 gals.:1998-93,000 jzals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd(Based on 15.203) Basis of design flow 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Never pumped-per owner and treatment plant System pumped as part of inspection(yes or no): No If yes,volume pumped: gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed(if known)and source of information: Appradniatety 1974-per owner Sewage odors detected when arriving at the site: (yes or no) No revised 9/2/98 Page 6of11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 570 Seaview Avenue, Osterville, MA Owner: Frances Corcoran Date of Inspection: October 30, 2000 - r BUILDING SEWER: (Locate on site plan) ) Depth below grade: Material of construction: _cast iron _40 PVC _other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints,venting,evidence of leakage,etc.) SEPTIC TANK: ✓ L (locate on site plan) Depth below grade: 16" Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 1000 gal. Sludge depth: 6" , Distance from top of sludge to bottom of outlet tee or baffle: 18" Scum thickness: -12" + Distance from top of scum to top of outlet tee or baffle: 9 _., _ __. _ ,� ,°='�r 'o Distance from bottom of scum to bottom of outlet tee or baffle: 4" How dimensions were determined: Measuring stick_.,_._ ., ._ Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) The tees and baffle were present. The liquid level was even with the outlet invert. There were no signs of leakage. Reconunend pumping. The inlet cover was under a patio and a hedge and was unaccessible. 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: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage;etc:) revised 9/2/98 Page 7oftl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 570 Seaview Avenue, Ostervllle, MA Owner: Frances Corcoran Date of Inspection: October 30, 2000 TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or 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: Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: None (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,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.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 570 Seaview Avenue, Osterville, MA Owner: Frances Corcoran Date of Inspection: October 30, 2000 tti� ,t ;T: ,�• :��,d trt r, c ,> + SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan, if possible;excavation not required, location maybe approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number: 1-6'x 6' leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields, number,dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) The pit had 3'of water on the bottom. The scum line was at the same level. There were no signs of failure. The bottom to grade was approximately 9' The cover was 28"below grade. CESSPOOLS: None (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: q Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection). 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: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.) revised 9/2/98 Page 9of11 r J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 570 Seaview Avenue, Osterville, MAMA Owner: Frances Corcoran } Date of Inspection: October 30, 2000 Map. 114 Parcel. 67 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 3AGk I Phi V I I I . revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 570 Seaview Avenue, Osterville, MA Owner: Frances Corcoran Date of Inspection: October30, 2000 '' •. a L °'?:>^ s :+�n11*�trL _.:'? NRCS Report name Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar r } Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record— Observed ✓ Observed Site(Abutting property,observation hole,basement-sump etc.) j Determined from local conditions j ✓ Checked with local Board of Health ., Checked FEMA Maps Checked pumping records Check local excavators,installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation..(Must be completed) The bottom of the pit to grade was approximately 9'. Using the Barnstable topographic map, the site has an elevation of 16'above the surrounding ocean. There is no high groundwater adjustment for this area. 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. revised 9/2/98 Page 11of11 �M r -45 .. - .* 3LAM - wia ISO s q G�►Asc. �� 'I s: , , `IJI M4 R'ct't-i� �R - S:P�:' cK R-���'•cw cam, -` No- -r-o Sc-k�-T� - � sr F C, • to-� •� No......... �_.... Fx�.:../1�.............. Ll'0((QQ/--7- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH U ' ,, 10 ` Appliration for Ditiposal Works Ton#rurtion Prrutit Application is hereby made for a Permit to Construct (v ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot ------------------------- ----- /" Pstaller er Address (�J Address / Q Type of Building (f '` �- Size Lot..__�� .�Sq. feet U Dwelling—No. of Bedrooms.._.__.__._.� .._. -----------Expansion Attic ( ) Garbage Grinder (4 `4 Other—Type of Building No. of persons--- �4 _ __ - _ YP _ -__ g -----------�--------"-_ P -•--L-,-----�•--. Showers (off) — Cafeteria Other fixtures~ - ` - = �.Y` � ------------- - w Design Flow.................... ..;___._____ 111ons per person per day. Total daily flow............ --------------gallons. W Septic Tank--Liquid capacity_/1W_ llons Length................ Width---------------- Diameter----- --- Depth---------------- Dis ---------------- Disposal Trench— o--------------------- Width............. _ T,�t��1 L,en i____-__. __----._/ Total leaching area______-________-_-_•s . ft. x _ �l P g� 9 Seepage Pit No... -------- Diameter... � �w e`f ..k_ Total leachin area------------------sq. ft. Z Other Distribution box ( ) 4osing tank ( ) tf-V )0G e Percolation Test Results Performed b � /7Xa Y :`; --.. Da e •----------,.-I Test Pit No. 1................minutes per inch Depth of Test Pit..............-_ Depth to ground water-_-_-______--___-___---- (1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................... P ----------------------- - -•---•...._........---- r O Description of Sol________________ x w UNature 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)byth board ✓� ( t�h Signed .......... ---_-. D_at ----J�k ��f ------------------------ 7--APPlication Approved f Application Disapproved for the following reasons--------------------------- ------------•------------------------------------------------•----. --•-----------------------------•-----------------------------------------------------•-•----------------•---•------••-------••-----•-•-----...... - ------------ate ------------------ Permit No......................................................... Issued.3----�--�- ---�--• ... .................. D to Fx�.••-- .. .✓�.... No......................... .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _...... OF....................................... . .......................................... �tration for Disposal Works Tonstrurtion Prrmit Application is hereby made for a Permit to Construct (� ) or Repair ( ) an Individual Sewage Disposal System at .............. �`7 a� �- f f �----•-•----- . ...................................-----------------...... . ---• � �L�ocation-Address _ { or Loft No f. 'L..t7'r.- £> :..i.iaa^:ix:.... ..._ ..........-' .LJ 6=-`......_!' �.... C,I CL_ / . caner t 1 Address ,/.� L>a - -r.i--3 _ F� — /1'�ccc X,I ....f. � ..fir!._" ......2. f'�.i° -------------------- nstaller Address r J° U Type of Building v ( g Size Lot--- f?c.✓� ! .� Sq. feet Dwelling—No. of Bedrooms............ ...... ...............Expansion Attic ( ) Garbage Grinder Other—Type e of Building No. person] y S r — Cafeteria ( - ) a, YP g t Q' 'Other fix ures . _.... --- -- -_----_-.. r� -- ...t?t�....��_._r ..........t........................... d 'l W Design Flow............. ::...... ............... lons per person per day. Total daily flow___..__. .----_.__----.gallons. WSeptic Tank-•Liquid capacity_j;-J $_a1llons Length................ Width................ iameter..........------ Depth---------------- x Disposal Trench—yo..................... Width._.___..._____ ..__ T -n -h:f �i tal leaching area-------------------- ft. Seepage Pit No. Diameter. _ _.- ept I bel TtOtal� clung a f tsgq. ft. Z Other 'Distribution box ( ) 'Dosindtank/( h" yejr--- aPercolation Test Results Performed by.......................................................................... Date.................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �Xq Test Pit No. 2................minutes per inch Depth of Test Pit-----_-----_.---_-- Depth to ground water........................ 04 -------------------------- - - --------•----.-.----•------------••--•----------..--•-•------•--------------•---------------•--•---------- DDescription of Soil------------------. -mot- c --------=`�_::.-•---------------------------------------------................................................................ x U ...... W ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- UNature of Repairs or Alterations—Answer when applicable................................................................................................ ---------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------- Agreement: f 7 ` The undersigned a �o ins Il e �# i e n ' Sgawage Disposal System yin accordance with the provisions of Artie tTfe' '(ate antfary ode—The u ersigned further agrees not to place the system in P operation until a Certificate of Compliance has been issued byt board o.Health. 4 Signed ----------------------------------- .................................. ....... Date ApplicationApproved By................................................................................................... ........................................ Date Application Disapproved for the following reasons------------------- --------------------------------------------------------------------------------------------- ----------•---------•--------•--------•-••-••••••---••-•••-•••-•--•---•••-----------------•--------------...--•-----•----------•-----•---•---------------------------------------•----•-••-•---••••------ Date Permit No................................................... ' Issued......................................................... _ Date THE COMMONWEALTH OF MASSACHUSETTS 'BOARD OF HEALTH ... ��... ., 5 ................... THIS IS TO CERTIFY, That the Individual Sewagg6zosal System constrt-cfe• ( r Repaired ( ) bY.................................................................................................................................................................................................... Installer at........................... --------------------------------------------------------•-----------------........ ..................... .......................................................... has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated........................................_....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. ---- ------------------------ inspectors r, r 1;0 THE COMMONWEALTH OF MASSACHUSETTS BOARD F°HEALTH OF..................-. --)----------------------- - No.................•--•--- ` f �#.................. Permissio �- Dinpo Marl, (�a fist�rurtion rrmtt g�.iLe hereby granted 1 A Ls .... to Cns 4.Kep i� `) an Irdividu 1 S/ age Disc poIN ystem r � 5.._Octf!� '/..'' Street as shown on the application for Disposal Works Construction re it No..:._z­'7 Dated.......................................... Board of Health DATE................................................................................ ' FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i cuo irk cl� ROW ON 0- ............ ---------- . ................................. 7AE • C)AIE F120AJ7' AAAD 7c) 0 S roiEA K11-Z YS, Lb ACCESS COVER (WATERTIGHT) TO TOP OF FNDN AT EL. 18.24 ACCESS COVER TO WITHIN 6" OF FIN. GRADE WITHIN 6" OF FIN. GRADE LEGEND r GROUND SURFACE AT EL. 17.5't GROUND SURFACE AT EL. 17.3't GROUND SURFACE AT EL, 17.2't GROUND SURFACE MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM --yy____ EXISTING WATER LINE APPROXIMATE LOCATION AT EL. 17.5 t WEST BAY X RUN PIPE'LEVEL EXISTING GAS LINE FOR FIRST 2' 2" DOUBLE WASHED PEASTONE -- 47----- EXISTING CONTOUR SITE Locus �.: PROPOSED7-50)0 it GALLON SE 14.4' (PROP.) 14.53' + 48.5 EXISTING SPOT GRADE TANK (H- AS BAFFLE `a' -= 13.76' Xr © C] M C1 O 71 M EJ ED og - 16- PROPOSED CONTOUR «� 1 .93 13',7' 71 0 a a C� a "4' ALL AROUND „ TH 1 � �2 34 SOIL TEST HOLE DEPTH OF FLOW = 4' \- 6" CRUSHED STONE OR MECHANICAL 2' 0 � 0 M Q E C7 M 0 SEE TEST HOLE LOG(S) ME TEE SIZES: COMPACTION. (15.221 21) CJ 0 � C] CD M Ca Cl s�AviEv+ 0 11.7� � UTILITY POLE, INLET DEPTH = 10 MIN BELOW FLOW LINE OUTLET DEPTH = 14" MIN BELOW FLOW LINE 3/4" TO 1 1/2" DOUBLE WASHED STONE CP EXISTING CESSPOOL NANTUCKET SOUND � (MIN 2% SLOPE) (MIN 1% SLOPE) (MIN 1% SLOPE) 5.8' EXISTING TREE FOUNDATION 1 1 ' SEPTIC TANK 47' D' BOX $' LEACHING FACILITY NOT ALL. SYMBOLS MAY APPEAR IN DRAWING LOCUS MAP BOTTOM OF TH 1 EL. 5.9' SCALE: NTS SYSTEM PROFILE 22' X 46' AREA IN WHICH THE NEW POOL, SEE SOIL LOGS ASSESSORS MAP: 114 PARCEL: 67 (NOT TO SCALE) SPA, AND HARDSCAPES WILL BE LOCATED DEPTH (IN.) TH1 ELEVATION (FT.) u POSSIBLE LEACH PIT APPROX. NEW C.B. NOTE: POOL MUST BE A MINIMUM O OVA 16.9 SEPTIC SYSTEM DESIGN DATA SEE NOTE 13. POOL LOCATION FND. OF 20, FROM THE LEACH FACILITY LOAMY SAND APPROX. LOCATION AND 10' FROM THE SEPTIC TANK 8" 10 YR 3 2' 16 23 SEPTIC DESIGN: ) EXIST. SEPTIC TANK / (GARBAGE DISPOSER IS NOT ALLOWED PROPOSED 1 ,500 GALLON Bw DESIGN FLOW: 5 BEDROOMS (110 GPD) = 550 GPD SEPTIC TANK - CENTER LOAMY SAND SEPTIC TANK: 550 GPD ( 2 ) = 1100 TEES (TYP.) DATE: MARCH 13, 2001 PE, PLS40" 2.5 YR 6/8 13.56 ENGINEER: ARNE OJALA, USE A 1500 GALLON SEPTIC TANK PROPOSED 20' WITNESS: GLEN HARRINGTON, IRS Cl SAND 1& GRAVEL LEACHING: M EXCAVATOR: BORTOLOTTI / X 26 ADDITION �F 1 62„ 2.5 Y 6/7 BOTTOM: 42 X 12.83 = 539 SF, EXISTING 11.73 SIDES: 2(42 + 12.83) X 2 = 219 SF. SCIL CLASS: I C2 y 00 PATIO �� 333 TOTAL: 758 S.F. X 0.74 LIAR = 560 GPD > 550 O.K. 24 GALLONS POURED IN 12: MEDIUM SAND 29��' PEtRC RATE: <2 MIN./INCH 2.5 Y 6/4 USE (1) ROW OF (4) 500 GALLON LEACHING BOTTOM PERC: 68" CHAMBERS WITH 4' OF STONE ALL AROUND 0 ti I I{ �� 11' 5.90 NO WATER FOUND NOTES: C.B. 1 THE LOCATION OF EXISTING UNDERGROUND UTILITIES SHOWN ON FND. y. 1�2 \ DEPTHS (IN.) TH2 ELEVATION (FT.) THIS PLAN IS APPROXIMATE. PRIOR TO ANY EXCAVATION ON THIS on CIT THC _EXCAI T)!JC Cnt lTP,nr rOR SHA,!_I MAKE THE REQ IIRFD 72 j-.--.- T o 0 0 o LOAMY SAND HOUR NOTIFICATION TO DIG SAFE (1 -$$$-344-7233)` AND ANY j D-BOX 10 YR 3/2 OTHER UTILITIES WHICH MAY HAVE CABLE, PIPE, -OR EQUIPMENT o i 500 GALLON LEACHING 17.13 /EXI TING DWELLING L2 N TH1 A 8„ Bw IN THE CONSTRUCTION AREA FOR VERIFICATION OF LOCATIONS. TOP of FNDN 1s.24' 1BERS WITH 4 DOUBLE �r ! WI HED STONE ALL AROUND LOAMY SAND 2. MUNICIPAL WATER IS EXISTING. LOT 194 42" 2.5 YR 6/8 14.3 3, ALL SEPTIC WORK AND MATERIALS TO CONFORM TO 310 CMR 53,356 S.F.t GARAGE C 15.00 TITLE 5 AND BARNSTABLE HEALTH REGULATIONS. \ 1 .22 ACRE t 8" PER FOOT.4. MINIMUM PIPE PITCH TO BE 1 MEDIUM SAND / 2.5 Y 6/4 5. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H-10. 6. PIPE JOINTS TO BE MADE WATERTIGHT. \ 7. WATER TEST D-BOX FOR LEVELNESS. 8. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE \ USED FOR LOT LINE STAKING. 9. PIPE FOR SEPTIC SYSTEM TO BE SCH. 40-4" PVC. DRIVEWAY ` ~ ✓ �0, NO WATER FOUND 7• 10. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT �. 8 INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED \ FROM BOARD OF HEALTH. 11 . NO VEHICLES OR CONSTRUCTION EQUIPMENT ALLOWED OVER 6 ------ TEST HOLE LOGS PROPOSED SYSTEM. (NOT TO SCALE) 12. VERTICAL DATUM APPROXIMATED FROM QUAD 13. PUMP DRY AND REMOVE, OR FILL WITH SAND, EXISTING LEACH PIT. G.B. \ � j FN OF TITLE T E 5 UPGRADE PLAN `7 -256 470 v off 508-362-4541 �6�4p• fox 508 362-9880 570 SEAVIEW AVENUE IN THE TOWN OF: ELEV. s 's.6' down cape engineering, Inc. (OSTERVILLE) BARNSTABLE TOP OF G.B. 41N Of Mq�:, �`v" 0f SITE PLAN CIVIL. ENGINEERS R PREPARED FOR: I CONSTRUCTION JOHN CORCORAN ARNE �`�:, o� ARNE H. 1 " = 30' / in SCALE: LAND SURVEYORS g H. ` g OJALA No 2s348 Noi30792 H 30 0 30 60 90 = �U"F• 9fCl T ���� ���© '$ '� `4 ----. . BOARD OF HEALTH 9 $ of �s E� �. 93 main st. yarmouth, ma 0205 1" 3Q7 MARCH 16 2001 01 -017 ARNE H. OJALA, PE, PLS DATE APPROVED BATE MA SCALE: = DATE: