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HomeMy WebLinkAbout0177 SEAPUIT RIVER ROAD - Health E eapo River0 014 a R y a �s ;I n 4 C { r � e f R o ,i { • Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a r 177 Seapuit River Road Property Address Richard Callahan Trustee Owner Owner's Name information is required for every Osterville MA 02655 9/9/14 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. General Information on the computer, I� 1 , 17 1. Inspector: use only the tab 6 11 U key to move your cursor-do not James Ford I ` use the return Name of Inspector s key. tab Company Name j .I P.O. Box 49 Company Address A Osterville MA 02655 City/Town State Zip Code 508-862-9400 S 12482 Telephone Number License Number B. Certification I certify that I have personally ipspected 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 Furt a Evaluation by the Local Approving Authority 9/10/14 In sp or's Signatu Date The tem 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 buyor,.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. 3 l5ins•3/13 Title 5 Official Inspection rm ubsurface Sewage Disposal ItemPage 1 of 17 a Commonwealth of Massachusetts Title 5 Official %Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 177 Seapuit River Road Property Address Richard Callahan Trustee Owner Owner's Name information is required for every Osterville a MA 02655 9/9/14 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: { ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 orlin.310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: ' r F. i 1 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, wW,ll pass. Check the box for"yes", "no",or"not determined" (Y, N, ND).for the following statements. If"not determined," please explain. 4.. 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.tre tank is less than 20 years old is available.- ❑ Y ❑ N ❑ ND (Explain below): i i E i t t5ins•3/13 I. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 if Commonwealth of Massachusetts W Title 5 Offici6 Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f! 177 Seapuit River Road Property Address Richard Callahan Trustee r Owner Owner's Name information is l required for every Osterville MA 02655 9/9/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): f' ❑ broken pipes) 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): i 5 4 �• ii ❑ 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): a . ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): t� �.• r, f � ! 4 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 I ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh I! . t t5ins•3/13 4. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 I - Commonwealth of Massachusetts Title 5 Officiallnspection Form Subsurface Sewage Disposaf System Form - Not for Voluntary Assessments R f. 177 SeaP uit River Road Property Address ly 3 Richard Callahan Trustee t Owner Owner's Name ` information is required for every Osterville + MA 02655 9/9/14 page. Citylrown f' State Zip Code Date of Inspection B. Certification (cont.). , 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". r. Method used to determine distance: E s_ . **This system passes if thr well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: i I g 3: u r F D) System Failure Criteria Applicable to All Systems: You must indicate "Yes'.. r"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static Itquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z.day flow is 15ins•3/13 p� - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I` r . i i r ;i fi f Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 177 Seapuit River Road F. Property Address Richard Callahan Trustee F ' Owner Owner's Name information is fj required for every Osterville MA 02655 9/9/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® Required. pumping more than 4 times in the last year NOT due to clogged or obstr,;uqted pipe(s). Number of times pumped: ❑ ® Any potion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portibn of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any potion 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 criter,iaexist 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 necelpspry 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. i 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 sys'.tem is within 400 feet of a surface drinking watersupply r, E] El the sjfstem.is within 200 feet of a tributary to a surface drinking water supply : .f El ❑ the sy'Stem is located in a nitrogen sensitive area (Interim Wellhead Protection Areai;"1WPA)or a mapped Zone 11 of a public water supply well If you have answered "yes;;t© 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 withi,3)0 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 11 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i i j , k: !j 1 i Commonwealth of Mas*husetts Title 5 Official` Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r"f '4 p 177 SeaP uit River Road Property Address is Richard Callahan Trustee i Owner Owner's Name ! information is required for every Osterville x MA 02655 9/9/14 page. City/Town Fj State Zip Code Date of Inspection C. Checklist Check if the following have Keen done. You must indicate "yes" or"no"as to each of the following: i, Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health rlt ❑ ® Were'any of the system components pumped out in the previous two weeks? ll ' ❑ ® Has th,e,system received normal flows in the previous two week period? ❑ ® Have lar�e 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 t(te facility or dwelling inspected for signs of sewage back up? f ® ❑ Was the,'site inspected for signs of break out? I; ® ❑ Were all.`system components, excluding the SAS, located on site? ® ❑ Were{he septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensipns, depth of liquid, depth of sludge and depth of scum? El ® Was thefacility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The siie 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. ® El 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)] t � i D. System Information Residential Flow Conditions: 9- per g Number of bedrooms (despr,i): Number of bedrooms (actual): ,k design DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 990 3' l5ins•3/13 $ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 (� a i s , Commonwealth of Massachusetts Title 5 Official" Inspection Form Subsurface Sewage DisposaljSystem Form - Not for Voluntary Assessments f; • a 177 Seapuit River Road =; Property Address ; . Richard Callahan Trustee ' Owner Owner's Name information is. required for every Osteryille MA 02655 9/9/14 page. Cityrrown 1 State Zip Code Date of Inspection D. System Informatidn Description: t!, r 1 f i . 4i f Number of current residents: 0 li Does residence have a garbage grinder? ❑ Yes ® No ;i, - Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) t Laundry system inspected? ❑ Yes ® No Seasonal use? F. ❑ Yes ® No FI Water meter readings, if av:ail,able (last 2 years usage (gpd)): Detail: unavailable f' Sump pump? I ❑ Yes ® No ;I Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: f: Type of Establishment: `. Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): I, Grease trap present? . ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No r , Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i, i Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal $y'stem Form - Not for Voluntary Assessments 177 Seapuit River Road 4 Property Address . Richard Callahan Trustee Owner Owner's Name information is i required for every Osterville MA 02655 9/9/14 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): t, 9 General Information Pumping Records: Source of information: e Was system pumped as part'of the inspection? ® Yes ❑ No i If yes, volume pumped: ., gallons How was quantity pumped;determined? Reason for pumping: maintenance 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!tof the I/A system by system operator under contract ❑ Tight tank;Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17II u Commonwealth of Masshusetts u Title 5 Officia-11rispection Form Subsurface Sewage Disposal,iystem Form - Not for Voluntary Assessments l s a 177 Seapuit River Road Property Address Richard Callahan Trustee Owner Owner's Name information is required for every Osterville MA 02655 9/9/14 page. City/Town State Zip Code Date of Inspection D. System Information_(cont.) Approximate age of all components, date installed (if known) and source of information: installed on 5/16/1989 -perdesign Were sewage odors detected when arriving at the site? ❑. Yes ® No Building Sewer(locate on",site plan): ri 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.): t . 4 i Septic Tank (locate on sito lan): f Depth below grade: t'`" 4 feet i I Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) I I If tank is metal, list age: F . years s , Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2000 gal.H-20 6 f i Sludge depth: 2 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 it ' t Commonwealth of Mass�'chusetts Title 5 Officid ♦Inspection Form a Subsurface Sewage Disposal,:System Form - Not for Voluntary Assessments s 177 Seapuit River Road Property Address I, Richard Callahan Trustee Owner Owner's Name information is Osterville MA 02655 9/9/14 required for every - page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness " 3 1 . v . Distance from top of scum to top of outlet tee or baffle 6 15• Distance from,bottom of sc m to bottom of outlet tee or baffle How were dimensions dete;Imined? measure Comments (on pumping recommendations, inlet'and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees were present. Steel covers were to grade. There were no sign of leakage. 4 y Grease Trap (locate on site plan): is 4.i Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: 1. 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 R Date of last pumping: Date l5ins-3/13 ; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 L Commonwealth of Massachusetts, Title 5 Officia'I Inspection Form Subsurface Sewage Disposal:.System Form -Not for Voluntary Assessments 177 Seapuit River Road Property Address Richard Callahan Trustee Owner Owner's Name information is l required for every OSterVllle MA 02655 9/9/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , a Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i i ; i . : Tight or Holding Tank (tani?, must be pumped at time of inspection) (locate on site plan): t% Depth below grade: Material of construction: ❑ concrete ❑ metal . ❑ fiberglass polyethylene ❑ other(explain): N/a Dimensions: + '' Capacity: a 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.): a Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No (Sins•3/13 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 177 Seapuit River Road Property Address Richard Callahan Trustee x' Owner Owner's Name `+ information is E. ' required for every Osteryille MA 02655 9/9/14 page. City/Town State Zip Code Date of Inspection D. System Information (cort.) Distribution Box(if present:must be opened)(locate on site plan): Depth of liquid level aboveoutlet invert even 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.): The D-box is under the driveway. A camera was used to inspect, per design plans on file all of the septic components are H-20 loadin a Y C ti Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition,pf,pump chamber, condition of pumps and appurtenances, etc,): i . n * If pumps or alarms are not in working order, system is a conditional pass. 1. . Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain:why: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 t: + 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal;aystem Form - Not for Voluntary Assessments 177 Seapuit River Road Property Address . Richard Callahan Trustee Owner I Owner's Name information is required for every Osterville MA 02655 9/9/14 page. City/Town i State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleri7s number: 6-galleys with 3'stone. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system E, Type/name of technology: Comments (note condition;of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): f The galleys are under the driveway. A camera was used and There was no sign of failure j Cesspools (cesspool must be as part of inspection) (locate on site plan): Number and configuration i Depth—top of liquid to inlet.�`nvert l. ' Depth of solids layer ., Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflA ❑ Yes ❑ No 15ins•3/13 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I 1' Commonwealth of Massachusetts Title 5 Officic-A, Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 177 Se_apuit River Road Property Address Richard Callahan Trustee Owner Owner's Name information is Osterville i required for every MA 02655 9/9/14 page. City/Town A State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition,', signs of hydraulic failure, level of ponding, condition of vegetation, etc.): E I Privy (locate on site plan):`' . Materials of construction: r Dimensions Depth of solids Comments (note conditionro •soil, Signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l , N/a t . ICI 7 i A f { • tl I p • i r' (Sins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 4 Commonwealth of Mas!§a:chusetts Title 5 Official: Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 177 Seapuit River Road Property Address Richard Callahan Trustee Owner Owner's Name information is required for every Osterville MA 02655 9/9/14 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 10o feet. Locate where public water supply the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately f ' CAf %J 3 L& / a a� a3 1- 0 0 a 3 ao �l 1 f !: 1 I ► r4 , 9, 6 rASS 16 l 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 i • Commonwealth of Massachusetts Title 5 Officiall�Inspection Form Subsurface Sewage Disposal' System Form - Not for Voluntary Assessments i, 177 Seapuit River Road Property Address Richard Callahan Trustee I Owner Owner's Name information is _ 02655 9/9/14 required for every OStervllle ; MA W page. City/Town i State Zip Code Date of Inspection D. System Information" (cont.) Site Exam: ❑ Check Slope R . ❑ Surface water . e ❑ Check cellar , ❑ Shallow wells f Estimated depth to high ground water: 20' feet Please indicate all methods Us' d to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked; date of design plan reviewed: pate ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with IQcal Board of Health - explain: Using topo and,water contours maps ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USgS database-explain: You must describe how you established the high ground water elevation: see above is s Y : R. Before filing this Inspection Report, please see Report Completeness Checklist on next page. i l5ins•3/13 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System.•-Page 16 of 17 l i f Commonwealth of Massachusetts - Title 5 Officia'I„ Inspection Form Subsurface Sewage Disposal system Form - Not for Voluntary Assessments a 177 Seapuit River Road ' Property Address Richard Callahan Trustee Owner Owner's Name information is required for every Osteryille i; s MA 02655 9/9/14 page. City/Town State Zip Code Date of Inspection E. Report Completenes's Checklist ® Inspection Summary: A, B, C, D, or E checked J '4 ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed I ® System Information— I estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file j r 6 . 4 t S �t 4 i Y 3gg . i� ij I a t ' 3 'I i' a • t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f t 1 a� TOWN OF BARNSTABLE LOCATION 1—)'J SePV r'�u t,r R�. SEWAGE# VILLAGE 0 31-6(VI ! ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY _ o�(� A- LEACHING FACILITY:(type) (o [�A�lhy IdcZo(size)�YSf/lt _ i,,,der NO.OF BEDROOMS ' OWNER k0(l\ 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 A Fpr� I �- A GArAge. � a� �q R - 3� ; COnc.re-Tt L31 a _ 1 , ' GAS S �1 TOWN OF BARNSTABLE 1f! LOCAtION 7 A /I- Awr I-d SEWAGE# / e . VILLAGE D/$yC'� /}dP(�/✓ASSESSOR'S//MAP&PARCEL INSTALLERS NAME&PHONE NO.-Dl'�/D,04, -fJ�y�J% �/• j�9 SEPTIC TANK CAPACITY q� //•Z, LEACHING FACILITY:(type) e.r.s (size) NO.OF BEDROOMS OWNER PERMIT DATE: kz COMPLIANCE DATE: (p 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 gollep 3 I f ' I -2-7 s /-L - ZI ; TOWN OF BARNSTABLE LO(:ATION � cSP G/r (ups / dVWAGE VILLAGE2'{&"Ille ASSESSOR'S MAP & LOT INSTALLER'S NAME A PHONE NO. V/i IAJQ S 3 6Z 3 6'KI- SEPTIC TANK CAPACITY l,Z)O LEACHING FACILITY:(type � (size) �(' NO. OF BEDROOMS_z 90 PUBLIC WATER BUILDER OR OWNER, R/�/S t�Jays j DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No qv d , gio CT- I � ' 1 r TOWN OF BARNSTABLE LOCATION /7 T Sewpuir R/w& a, SEWAGE if VILLAGE 05 Mawi,c g ASSESSOR'S MAP A LOT��0-� INSTALLER'S NAME A PHONE NO. Q D_S TZ L SEPTIC TANK CAPACITY d741 i LEACHING FACILITY:(type) 10930 NO. OF BEDROOMS•�—PRIVATE WELL OR UBLI ATER BUILDER OR OWNER &IG#*a/JLc/�.�1e��- i DATE PERMIT ISSUED: '-30- If i i DATE COMPLIANCE ISSUED; -✓�! VARIANCE GRANTED: Yes No G 4/cjo.E-A 40rrow j t � � I TOWN OF BARNSTABLE LOCATION S e V+ f- v c.r R'cj-- SEWAGE# VILLAGE O 3Tee,(V,I� ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY c -QM LEACHING FACILITY. (type) G G 16(20 size)3` nA - ( �Ae.( NO.OF BEDROOMS G OWNER 1 0 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 'rf1-fie.CT10) ��('� Q ' aa` a3 ,3\ Con c..rc.Tf— � a . 1 GLASS `� TOWN OF BARNSTABLE �� 7� �11/?0� �Gl. SEWAGE#. L�J..�IION �7' �� /JP' -VILLAGE //OtAPOASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. tDI /O�OO ��`Pyf: �/• j�� SEPTIC TANK CAPACITY 200 70 / •Tvp LEACHING FACILITY:(type) (size) NO. OF BEDROOMS OWNER Q PERMIT DATE: IrIL ®6 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 "z"mlk .-ast TOWN OF BARNSTABLE LOCATION -5 C-*l m /v EWAGE # VILLAGE U,S t2 01//e— ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. 3 3 SEPTIC TANK CAPACITY /�� � e LEACHING FACILITY:(type (�11 (size)_ I x:� NO. OF BEDROOMS 7 M PUBLIC WATER BUILDER OR OWNERL,�,/�p �j/S ip-JO t DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No � 1 o�° v� (� t ,� r TOWN OF BARNSTABLE LOCATION SEWAGE # �1�'�y VILLAGE ®5,�[-���i��,� ASSESSOR'S MAP 6z LOTf ��t?�/ INSTALLER'S NAME & PHONE NO. Zd�—j- 2/&22 S2 c, SEPTIC TANK CAPACITY ODD D C2 C4 t LEACHING FACILITY:(type) Y�, (size) la 3 O NO. OF BEDROOMS- PRIVATE WELL OR UBLI ATER BUILDER OR OWNER .DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No _ I iCA a W y O Y t I• S - l Message Page 1 of 1 Stanton, David From: Stanton, David Sent: Wednesday, June 12, 2013 9:08 AM To: 'john@sullivanengin.com' Subject: RE: 177 Seapuit River Road, Osterville John, That is correct. Septic permit 88-690 was approved and permitted by the Health Division for a total daily flow of 990 gallons per day, which is the equivalent of 9 bedrooms. According to the Title V definition of approved capacity, it is the lower of the two numbers (permit and certificate of compliance) and in the case of the Town of Barnstable, there was no flow indicated on the certificates of compliance, so it is just the approved capacity on the permit. I will print out this e-mail and place it in the street file as confirmation as well. Thanks, David -----Original Message----- From: John O'Dea [mailto:john@sullivanengin.com] Sent: Tuesday, June 11, 2013 12:38 PM To: Stanton, David Subject: 177 Seapuit River Road, Osterville David, As a follow up to our discussion on Friday June 7, 2013 this email is to confirm that the parcel located at 177 Seapuit River Road contains 9 bedrooms as is indicated in the assessors records,and that this flow does not exceed the Approved Capacity of the existing system as per Disposal Works Construction Permit No. 88-690. Please confirm that this email is sufficient documentation for your records. John O'Dea, PE Sullivan Engineering Inc. 7 Parker Road/P.O. Box 6S9 Osterville, MA 02655 508-428-3344 508-428-9617 (fax) 6/12/2013 No. . `f�-. . . s Fee �lJ THE COMMONWEALTH OF MASSACHUSETTS Enaed in computer: .PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplicatiou for �Bigonl fppgtem Cou5tructiou Permit Application for a Permit to Construct( ) Repair( ) Upgrade I v Abandon( ) ❑Complete System KIndividual Components Location Address or Lot No. %7"j S E:APtr 1 2%V RvZ-�Z\0 Owner's Name,Address,and Tel.No. S -AZR.r M3°'4 E-t5 C 2 %a es 0s-1�2.V iLj-C 2+cbw20 CA�La I-4 �2vS�EC� C>AZ0 (-0fZ9, Assessor's Map/Parcel vTo/O k A i 'S e APu Cr 'Q\v EQ(LOAD 0YS�1Z\AAtt30Q-.5 sbs- s'n '1�1-9399 ® Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 42$-'33A¢ Sae�cw-r�-t co"t-Nr2..m0k.X �s1n�Q�s,tey Qo mierZ Su>~�i Jr t c Marls ,ys Mt��s a2 SuLLwA,►a sl ?A"Ct i4>0SMZVi Type of Building: t Dwelling No.of Bedrooms AJ Lot Size 9 - Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Ao,)y S LoGPNTt.Q" ® .0 6 0 ko Flat \ n(=1= F'U-WV2C hQ0C'-),10CJ i VIA C-QIATETCA4.15 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 Certificate of Compliance has been issued by thWar eal Date xo Signe Application Approved by w d Date t oV G Application Disapproved b Date for the following reasons Permit No. 2bo6-- 117 Date Issued .•r ' No. �u � � •3 �� l i� ,�,� y � � ' \ Fee LJ� /Vl vl ' 4,, +EAded in computer: t� THE COMMONWEALTOF \MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rpplicat ou for 3iqozal *pztem Cougtructiou Vermtt Application for a Permit to Construct O Repair('p Upgrade�; Abandon O ❑ Complete System QIndividual Components Location Address or Lot No. \'71 I&EA P u 17 ( %V Uii-\Z\7 Owner's Name,Address,and Tel.No. 4.-C$5_AZZ_33,A4 Cea�L . O�[5 1�« fZ,eo-.ArL0 c?.,Nl'`����'Oi2S Os i�Ld 1 LLG w. �,'�`�-T2vsc� _CJ�C4o C�2P, Assessor's Map/Parcel 710101 A 1 77 J K E APu I-T \v EI-(ZOAO 0ySTeZ-N\AZ 30Q S Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Z\Z 5 ¢ N60Q-T0L-C)-rTt Co1JST`2VCMOt.A d�'typvSZ12Y QJ ��•G 1 E L Su L Ll vHi i i;1 rr,, N1p,2S�luS M11-LS 02(-48 JuLLkvA�,A ENG.•l,vC• "7 IPA,LY-C.e- 4> &C 2VII1Z Type of Building: / n t Or Dwelling No.of Bedrooms IUJ 1 )�' Lot Size �3 -s =f#= 6Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other'Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 1 Nature of Repairs or Alterations(Answer when applicable) A D J u f> LoC Ti D Lk 0 F E>,\S\t t- Ec SG of C _i TA1\Ar Tn Q-,E \0 IP _E� 0(Z FQTU(Z.0 .&VQIi,0t'Q % \ o �.nnc�,a�= PLAt� FU2- A9-�> l Tl O 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 Certificate of Compliance has been issued by thisoBoard o:f Ht7i / ` / ' Signe Date xgApplication Approved by � v lA. Date Application Disapproved b Date for the following reasons Permit No. 7 b U 6- Y7• - Date Issued .I 1 1;2 Aq 6- r s p),� 1k� 1 THE COMMONWEALTH OF MASSACHUSETTS ( p�loch ! 1 / BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded (,k^ ) Abandoned( )by at \7-1 S EA>'U I T 2\Q Ei2_ Qn r) DYst1-.iZ�11Rs_ 1Q5 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ,?00�- y7 2 dated111.2)o6 Installer �02T0L0TT 1 wF.1STlZ�CCtOdJ� Designer F-T�i� 'SU/L I--\ \1Nt A ►?� #bedrooms Al I A- Approved design flow n1/A gpd The issuance of ht si permit shall not lbe construed as a guarantee that the systemwill fu c on s designed. Date I l . I G� Inspector` L_^� U v No. a -! Fee / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS &5po5al *pgtem Cougtruction permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) System located at 1-7-7 S E&201 i 2►�I�'1�� Qn .n nYSTE? 1�P,2-(--,rx?C 05ir—eV\LLB and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construct on must be completed within three years of the date oft-is pe it. Date � '21Q�o Approved by �T, v L'}� 4 s It ;ti" ( r� 5 1 _ l� r , n Fzo 1 '� ExIST: GALLEIIS t r PETER SULLIVAN a � .2973J � ' q r CONNECT N —W PIRF--rO CIVI ! 00 O ESA 1 0 Z t . .. " RE'1-0CATB r:xls'�'. aOOO GAL. :. O FOR e_XIS-I-: SEPT1r__ 'SePTC TANK A3 :aHOWKI SYSTEM SEE PERM\r'. No. 4 qo \ A PPROX \_COCA I I O P.1 R X 1ST - CONNEGTh\�W P\Ph TO SEPTIC TANK EXIST, House SE\"r-K wX 157. Septic Tank Relocation r-„T,_I R r 177 Seapuit River Road Ap"ITIOH Oyster Harbors, Osterville —1 "—' '—r Sullivan Engineering,Inc. Gx1ST. 1+o�sE I Osterville Mass s ew�R i October 31,2006 _ PLAN VIEW s c o W- 1 20': Town of Bkrnstable ` tZegul'kor Services 16 � Thomas F G Ieilei,Director M _ luti�c Health Division Thdfiias le%eKeah, Director 200 Main Street,HYaaw is,MA'02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form 2oob— ' Date: I/ e.lo G Sewage Permit# H-7 z Assessor's Map\Parcel ono o y Designer: Suw-tVAN 61yc-jNagaiNt Installer: PoRToLo'TTl Con.5rA4r tor- -7 PA-R.Kem MP 46 INoq8t12y 12D. Address: 0 s'r6 RV 1 L Le , M,4 s $ Address: M ARs't0P$ MILLS On ►t.1210 G 56,r&L&TTI Caws was issued.a permit to install a (date) (installer) septic system at 171 SCUMI FQIvfa ¢p. based on a design drawn by 5"1-41 vAN (address) c-Iv4iiv Eaiwy Mc .. dated. is/31 ,1o6. (designer) v I certify that the septic system referenced above was installed substantially according to the design, which m y 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-built by designer to follow. OF (Installer' Signature) mn- (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 Forma-26-04.doc f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION . TITLE.5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 177.Seapuit River Road Osterville:MA'02655 �. Owner's Name: William Koch` Owner's Address: Date of Inspection: January 15, 2013 Name of Inspector; (Please Print) James M.Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ }'asses .: Conditionally Passes eds Further Evaluation by the Local Approving Authority Fai s Inspector's Signature: Date: January 17, 2013 The system inspector shall sub t a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different , conditions of use. t Title 5 Inspection Fonn 6/15/2000 p page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 177 Seapuit River Road Osterville,MA Owner: William Koch Date of Inspection: January 15, 2013 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,NIJ) in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or'exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken.pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE CTION FORM PART A CERTIFICATION (continued) Property Address: 177 Seanuit River Road Osterville,MA Owner: William Koch Date of Inspection: January 15, 2013 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. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 u Page 4 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _ 177 Seanuit River Road Osterville.MA Owner: William Koch, Date of Inspection: January 15, 2013 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution'box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool;or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool;or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool'or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of,the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-.IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 I ' Page 5 of 11 OFFICIAL INSPECTION,FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 177 Seanuit River Road Osterville MA Owner: William Koch Date of Inspection: January 15 2013 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 constructiolt,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(arid occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. - 5 y 'i Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 177 Sea uit River Road Osterville MA Owner: William Koch Date of Inspection: January 15, 2013 RESIDENTIAL FLOW CONDITIONS ` Number of bedrooms(design): 6 ;Number of bedrooms(actual): 6 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 660 Number of current residents: N/a Does residence have a garbage grinder(yes for no): Yes Is laundry on a separate sewage system(yes or no): N/a [if yes separate inspection required] Laundry system inspected(yes or no): no Seasonal use(yes or no): no Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Summer use COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sq/ft etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons-p 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: Date of installation 1988 ver as-built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) i Property Address: 177 Seapuit River Road Osterville,MA E ' Owner: William Koch Date of Inspection: January 15, 2013 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) i. Depth below grade: 4' Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 2000 Qal. H-20 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 10" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: ` Measurinz stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage;etc.). Tees were present. The tank is under the concrete driveway. Steels covers are to Qrade. GREASE TRAP: None (locate on site plan) P ' Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet the or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 177 Seapuit River Road Osterville.MA Owner: William Koch' Date of Inspection: January 15, 2013 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day ` Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: i Comments(condition of alarm and float switches,etc.): 4. DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) j. Depth of liquid level above outlet invert: Even 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.): The D-box was normal. A camera was used for the inspection The D-Box is under the concrete driveway. Per the design plans on file all of the septic components are H-20 loading 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.): f It - ;1 8 f - Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART C SYSTEM INFORMATION (continued) t Property Address: _ 177 Seapuit River Road Osterville MA Owner: William Kochi Date of Inspection: January 15, 2013 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: 6-joallevs with 3'stone and 1'under 30'x10'per design 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.): There did not appear to be any signs of failure The galleys are under the concrete driveway with no access Per design plans all components are H-20 loading. CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Continents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ;i Property Address: 177 Seavuit River Road Osterville,MA Owner: William Koch Date of Inspection: January 15. 2013 c . SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal systemuncluding ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. �1 A- GArASt i ace aq Q - - 3� Con C.rc,Tt-. °� c-�` ' 1 - 0 O a 1 I CrAS_S ` 10 f I. :• Page 11 of 11 f. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 177 Seapuit River Road Osterville•MA . Owner: William Koch Date of Inspection: January 15, 2013 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20+1- feet Please indicate (check) all methods used to determine the high ground water elevation: i Obtained from system design plans on record- If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health_explain: Topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain:. You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps the maps were showing approximately 20+/ to ground water at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the fixture. There have been no warranties or guarantees,either expressed, written or implied, relating to the septic system,the inspection, this report and/or any components of the septic system which have not been located and inspected. QQ `lc) LCTT 1 No....0.-.&fie' y k AFRs. 76............._ THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH ®� � rj l 4- Appliration for Uiipoii al Works-Zonitrnrtion ramit U ec-tf-A.0G Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal,,'„ syst �• a EA?()1T e u 6t2 0 A. s tac ,,ll �. ...._... .- ............ ............ ----..........._.... '(.. ._....�2...! T I �aC�Q ..-•-...•-••-•-......._... ----- ocay -Address —�. or Lot No. L 1':. 1. ► 1�,L �t�tram._. Vs c....: ?Sl ® .. 5�1� lvvU t.3 ?�3_> 1 .Sr._�,O� wl _ ..... wne'r A�n ` Address W ......................... ..... 1..^sue..__...... .................................................................................................. --•-•-••--•-•--------------------•----.. Installer Address A G��5 Type of Building �-o.� Size Lot., 39./.......__..._.. U Dwelling—No. of Bedrooms___ ____________________________________Expansion Attics Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures -•---•-•---•-------•------------ . -- W Design Flow....b— .50.... .............gallons per person�per�day. Total daily flow....99.0..........................gallons. r i WSeptic Tan�l —Liquid capacity.' __._gallons i ength 1L-1�__.... Width _._.._ Diameter--------------- Depth..S---(o__-. x Dispo�rench—No...__�............... Width....101......... Total Length............ Total leaching area. 7.OQ_..._._._sq. ft. Seepage it No--------------------- Diameter..................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box da Dosin 2�t"a"n�""k ( t� '�' Percolation Test Results Performed by._T �1Sl e-1..[ `(. _ln��c.�__________________ Date._lt�__l.` °_� -------------_- Test a Pit No. 1.L. ______minutes per inch Depth of Test Pit__W,_&._..._.._ Depth to ground water4QT54AW.,.,MeG-.l Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water......__-__-_-____--_--. .----------------------------------------•--•----............----------------•---------...---......................................................... 0 Description of Soil-----Q.-^-;-; .._. ---------•------ x W -------------------------------•------------•--••------......-----------•--•----------••-...•--•----•--•••--------------------•-------------•------•••--•-•-----------•---•------••-------------•--- VNature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------------____-_-______. --------•---------------------------------------------- ------------------------------------------•---------•-------------------------------------------------------------------------........_•--••---- Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with T1-1-'^ the provisions of :.T: t IE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... Date Application Approved By------ -----------------•-•-•----_--•---•-•------ 1 ' '`-=' .-`1------. Date Application Disapproved for the following reasons:-------•-------------------••-•-----•-------------------------------------------------------•---•---------_----- ---------------------------------------•-----•----•-------•-----------------------------•-----------•--...---•----...._...------•-----------------------•--•----•---------------------------•------------ Date PermitNo........KiLA 16------------------------ Issued....................................................... Date /O No.� _:_.�(. Fes$. _............ THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH i �-ice.. . .............OF.. ►Z�U`a Appfiraation for Uhywiaai Workii Tomptrurmiaa ramit u'P�Zj'.�C>G Application is hereby made for a Permit to Construct ( ) or Repair (X an Individual Sewage Disposal System at: ,l 0-7 S' L-r� u i E.Z 1�•a �O . ..... ---•-----------------------••------•---- ocat -Address 1 •- (� or Lot No.?-a? r� 1 us ....-- >< , u. ..._1�-._Prw wt Owner Address ........................•-•-••-- Installer Address 3�' L� Q Type of Building F-© L Size Lot__�4_____ _______________ Dwelling—No. of Bedrooms____ ___________________________________Expansion Attic (19 Garbage Grinder (� 5 aOther',. Type of Building ____________________________ No. of persons____________________________ Showers ( ) — Cafeteria ( ) Q' Other fixtures _________________________________ _ W Design Flow...... ............gallons per person per day. Total daily,flow_____- _O.........................gallons. WSept6.Tauk�—Liquid capacity_ gallons Length__ll_-_. Width_ ______ Diameter_____ _______ x Disposal rench—No......1.............. Width.....tQ__........ Total Length__._........ Total leaching area__71W........sq. ft. Seepage'it No-------------_------ Diameter_._.________________ Depth below inlet.................... Total leaching area............_.....sq. ft. Z Other Distribution box ( 4s, Dosin ank (�+�1� ~' Percolation Test Results Performed by._._t"Jx ! _ `1C__�h.l�A.__________________ Date_��__� _:B ... ............ ,`l� Test Pit No. l... _2__._.minutes per inch Depth of Test Pit._.1��_ _........ Depth to ground watert`c)r&Acou�+�:c�tZE� r3. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-_________________-____ O DescriptionofSoil-----D._ ,-L____b04 ____ _. U -••••--•---••...--•---••-••-•---••--••••--••----••-••--••--••••----------•-----•--•••-•---•------•--•---•---•---•---•---•-••----•••••------------•-----•---•----•-•••-•----- w UNature of Repairs or Alterations—Answer when applicable........................_....................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with /-1¢ •• the provisions of TT 1. "LE of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...................................................................................... ................................ Date ApplicationApproved By-••--• -----------`--...-.....-.......---------•------------------------------- ----------- ----- Date Application Disapproved for the following reasons-----------------------------------•---------•-----------..•---•-------------•-----------------------------•••--- ...............•--•-••--•-------•-----•-...__.__..-•----------------•-•------•-•--••-•------------...-•••'-•----•-------•------•-------•-•------••------------••----•-••---•-••••------•-••--•--•-••----- Date PermitNo............ = ...................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / ............ /?�fitr E......OF...................... rr a. eor........................ Trrtifiratr jaf T. mpliFaaur THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - Installer has been installed n�ccor anc wi the provis--- ^� x �?___________________________________ at.--••----•-••-- --•- s of TITLE of The State Sanitary Code as described in the application for Disposal Works Construction Permit No______________ _=__�. _�l___ dated------------------------------------____________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION) SATISFACTORY. DATE.................... '...�..�/ ................ Inspector.................... ......................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Fit NO._..... LIB ./1 FEE..... R111111s al --ark. (Iaiaao#ra uan an it Permission is hereby granted__.______ "r ` ...........................•-•=--•---•••-•---•--•..._...••---•-•---•-•--......-•-•.........................•- to Construct ( ) or Repair ( �<a.n Individual Sewage Disposal System / atNo. �= ~i -..... ...- .�.l --�----------- =" .. .............................................. l� Street as shown on the application for Disposal Works Construction Permit No. tedl '� '� ....... '+ --------------•-------•-••-•---•---___=--•-•--_''"`�c--------------•--•----_____- yA •,� Board of Health DATE.--••--••--� ---`�"''- �� ---------------------•---------••--- FORM 1255 BBS & WARREN, INC., PUBLISHERS I BAXTER & Imo., INC. Professional Land Surveyors and Civil Engineers 812 Main Street • Osterville, Massachusetts 02655 . Tel. (508) 428-9131 WILLIAM C. NYE, P.L.S. - President PETER SULLIVAN, P.E. -Vice President-Engineering RICHARD A. BAXTER, P.L.S. -Vice President November 21, 1988 Town of Barnstable Board of Health P.O. Box 534 Hyannis, MA 02601 RE: 177 Seapuit River Road - Oyster Harbors Septic System Upgrade Dear Board: Please find attached a site plan for Mr. Koch' s home in Oyster Harbors . An addition has been proposed where the number of bedrooms will increase from 4 to 6 . The septic system has been sized as per your agent' s recommendations. The proposed system is in excess of 200 feet from a resource area' and at least 14 feet above ground water. Please note that the test hole was unable to cover the full four foot depth below the proposed system. It is my professional opinion,-'.that the required. depth of suitable material is present, however, I will gladly verify this at the time of installation. I trust that this meets all. the .Boards present requirements and look forward t6 your favorable review. If you have any questions., please do not hesitate to call . Very truly yours, Peter Sullivan, P.E. Baxter & 'Nye, Inc. PS/fmj ti OF �r Encl . ° F14,7ER yG�� SULLIVAN cc : Mr. William Koch No. 29733 Mr. Richard P. CallahanIST F MEMBERS OF CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS I AMERICAN CONGRESS ON SURVEYING AND MAPPING MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS I, a , r 6. p psu Islan J � ° �• f '�7 L t\` t p'D�, , ory°/ O p p 0�� : ,,• ._ Oe� - F $G.� Cam' I� '• {,!VTF— ./ T F7�l. E'. 1ri7XTC e fA7E"1KA O $ Island �+ •Pond .i C 18" QS'�t:.C. �•1S�@S t0 �C-x (� p $ e Isabelle14 ITK L.'Z, lreA'1.E irC046Z- o _ _ III •�1 N :;.' s i " 4 rr '5c�� 40 'c 2010 O Public / •, Ek�b C , tU� Z2 0 -Cam• ;, ... p BR l SHOO• h!� Tims Tema .. •. _ t iiAV Pt o 1 .. 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