The URL can be used to link to this page

Home My WebLink About0284 SEAPUIT RIVER ROAD - Health 284 SeapuitRiver Road Osterville P A 051. 017Q01, / t i �,II 4 LY�.: •. :, �. ' ✓Frig.. I i i (9 V ' Z00 600 1 r '�' Commonwealth of Massachusetts 037-6�� -Doi - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^.,a 284 Sea uit River Road P rr Property Address P Y Katharine & Charles Lin amfelter Owner g Owners Name 4a�+ information is required for every Osterville V MA 02655 11/15/2017 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 A. General Information filling out forms � �/�. /�—7(a C} on the computer, use only the tab 1. Inspector: key to move your cursor-do not James Ford use the return Name of Inspector key..'. ' Ford Septic Services, LLC Company Name P.O. Box 49 Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S12482 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported,below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails Needs Further Ev u tion by the Local Approving Authority 11/17/2017 I nspectoNiSignature Date The sys'4n inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the.approving authority. ****This.report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 vs Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M a,•''• 284 Seapuit River Road Property Address Katharine & Charles Lingamfelter Owner Owners Name information is required for every Osterville MA 02655 11/15/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for"the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): " t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •4M 284 Seapuit River Road - Property Address Katharine & Charles Lingamfelter Owner Owners Name information is required for every OSterville MA 02655 11/15*/2017 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 284 Seapuit River Road Property Address Katharine & Charles_Lingamfelter Owner Owners Name information is required for every Osterville MA 02655 11/15/2017 page. Cltyrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 284 Seapuit River Road Property Address Katharine & Charles Lingamfelter. Owner Owners Name information is required for every Osterville MA 02655 11/15/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply pply well. ❑ ® An portion of y p a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .284 Seapuit River Road Property Address Katharine & Charles Lingamfelter Owner Owner's Name information is required for every Osterville MA 02655 11/15/2017 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS,.Iocated on site? ® ❑ Were the septic tank manholes uncovered; opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, . dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ :Determined in the field_(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms). 550 t5ins•3/13. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments a 284 SeaP uit River Road Prop erty Address Katharine & Charles Lin amfelter Owner Owner's Name information is required for every Osterville MA 02655 11/15/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? - ❑ Yes ® No Seasonal use? El Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail" unavailable Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�.-A,•'•y 284 Seapuit River Road Property Address Katharine & Charles Lin amfelter Owner Owners Name information is required for every Osterville MA 02655 11/15/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(tti 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 OEP approval. , ❑ Other(describe): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 284 Seapuit River Road Property Address Katharine & Charles Lingamfelter Owner Owner's Name information is required for every Osterville MA 02655 11/15/2017 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: system installed - 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 24" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ®other(explain) If tank is metal, list age: d years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 2- 1000 gal Sludge depth: 1 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 284 Sea uit River Road Property Address Owner Katharine & Charles 'Lrn amf elter information is Owner's Name • required for every Osterville MA 02655 11/15/2017 page. City,—,- State ZipCode 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 4 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 14 How were dimensions determined? 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.): There were 2 tanks in series. The tees were present. no sign of leakage. Grease Trap (locate on site plan): Depth below grade: n/a feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 10 of 17 . Commonwealth of Massachusetts . W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M e 284 Seapuit River Road Property Address Katharine & Charles Lingamfelter Owner Owners Name information is required for every Osterville MA 02655 11/15/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete. ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 • Commonwealth of Massachusetts ' = W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 284 Sea uit River Road Property Address Katharine & Charles Lin amfelter Owner Owner's Name information is required for every Osterville MA 02655 11/15/2017 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.)' Distribution Box present if ( p nt must be opened)p )(locate on site plan): ) 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 Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: El Yes ❑ No* Comments (note condition of pump chamber, condition of pump's and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 • Commonwealth of Massachusetts s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `��A,•`'� 284 Sea uit River Road Property Address Katharine & Charles Lin amfelter Owner Owner's Name information is required for every Osterville MA 02655 11/15/2017 page. City/Town State Zip Code Date of Ins D. System Information (cont.) p ection Type: ❑ leaching pits number: ® leaching chambers number: 7-rechar ers ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There was no sign of backup or failure from rechar ers A camera was used to inspect Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—.top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 • Commonwealth of Massachusetts L = Title 5 Official Inspection Form aX Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 284 Sea uit River Road Property Address Katharine & Charles Lin amfelter Owner Owner's Name information is required for every Osterville MA 02655 11/15/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�•, 284 Sea uit River Road Property Address Katharine & Charles Lin amfelter Owner Owner's Name information is required for every Osterville MA 02655 11/15/2017 page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A ' O a O � 3 0 � � � y Y3 a? q9 t F 3 s'6 13 y s1 r I+ 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 •� Commonwealth of Massachusetts H v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •`'�F 284 Sea uit River Road Property Address Katharine & Charles Lin amfelter Owner Owner's Name information is required for every Osterville MA 02655 11/15/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20' +/- feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Topo and water contours map ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high groundwater elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M a••''• 284 Sea uit River Road Property Address Katharine & Charles Lin amfelter Owner Owner's Name information is required for every Cisterville MA 02655 11/15/2017 page. City/Town State Zi Code P Date of inspection- E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ®Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTALPROTECT RECEIVED MAP a 51 .., JUN 2 9 2004 PARCEL ;_0 1-7 0__U___ TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 284 Seapuit River Road OsterWlle, MA 02655 ® o Owner's Name: Jody Hines �.. Owner's Address: 61 Beacon Street 0 Boston,MA 02108 -� ry c-nrn Date of Inspection: May 20, 2004 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford 3' Mailing Address: P.O.Box 49 C) rn r' Osterville,MA 02655-0049 'j Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes „ Conditionally Passes Nee Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: May 22, 2004 4 The system inspector shall subm' 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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 284 Seapuit River Road Oslerville, MA Owner: Jody Hines Date of Inspection: May 20, 2004 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,ND) in the for the following statements. If not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 t Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 284 Seapuit River Road Osterville, kM Owner: Jody Hines Date of Inspection: May 20, 2004 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: I 3 Page 4 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 284 Seapuit River Road Osterville, MA Owner: Jody Hines Date of Inspection: May 20, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level-in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy.is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone I 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 Page 5 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 284 Seapuit River Road Osterville, MA Owner: Jody Hines Date of Inspection: May 20, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ _ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components, excluding the SAS, located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,.dimensions,depth of liquid,depth of sludge and depth of scum? ✓ Was the facility owner(and occupants if different from.owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 284 Seapuit River Road Osterville, MA Owner: Jody Hines Date of Inspection: May 20, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 0 Does residence have a garbage grinder(yes or 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: Weekend use COMMERCIAUINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Qpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION ` Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy. Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed 12117196-per 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) Property Address: 284 Seapuit River Road Osterville, MA Owner: Jody Hines Date of Inspection: May 20, 2004 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: 1(2-septic tank&settling tank) (locate on site plan) Depth below grade: Both 20" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: _2"(septic tank) Distance from top of sludge to bottom of outlet tee or baffle: 30"(septic tank) Scum thickness: S"(septic tank) Distance from top of scum to top of outlet tee or baffle: 6"(septic tank) Distance from bottom of scum to bottom of outlet tee or baffle: 12"(septic tank) How were dimensions determined: Measuring 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 liquid level was even with the outlet invert. There did not appear to be anLsigns of leakage. Tees were present in the second tank(settling tank)and lust liquid was present. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 284 Seapuit River Road Osterville, MA Owner: Jody Hines Date of Inspection: May 20, 2004 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: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) 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 clean. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 f Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 284 Seapuit River Road Osterville, MA Owner: Jody Hines Date of Inspection: May 20, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 7 rechargers with stone leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): There did not appear to be any signs of failure or backup from the SAS. A video camera was used for the inspection. 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: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 I Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 284 Seapuit River Road Osterville, MA Owner: Jody Hines Date of Inspection: May 20, 2004 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A i O Q H (3 a Q y3' a? 3 O a yq g 3 S'6 13 y 10 f Page 11 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 284 Seapuit River Road Osterville, MA Owner: Jody Hines Date of Inspection: May 20, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20 +/- feet Please indicate.(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: 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 maps and water contours maps the maps were showing approximately 20'+/-to ground water at this site. 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 andlor this report. I 11 TOWN OF BARNSTAB LE n y rya jy LOCATION T v cl�U' SEWAGE # G ti L - VILLAGE 0,9�C V'V G e ASSESSOR'S MAP& LOT s INSTALLER'S NAME&PHONE NO. Gw 7 — -�42 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) C50-S (size) NO.OF BEDROOMS BUILDER OR OWNER Y " PERMIT DATE: 3®: G COMPLIANCE DATE: J zT/(h7/4 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 ofWetland and Leaching Facility(If any wetlands exist within 300 feet of eaching li Feet Furnished by KZ V, U -C T CIA (ICA_. r o u TOWN OF BARNSTABLE LOC'f`I ION agy SV f lUf� Q� SEWAGE # 9 G- 5� VILLAGE OSf rv► Lk ASSESSOR'S MAP & LOT 100 f z INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY a "n- _�' GAI m Seyii,t LEACHING FACILITY: (type) ��a (size) NO.OF BEDROOMS BUILDER OR OWNER 3 - PERMITDATE: 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 leachi g facility) Feet Furnished by ey Jon �d/ W ap a 0 . 00 F 1 _7 0/ l '' Oe t1 tS too THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migogal *p5tem Congtructfon Permit Application is hereby made for a Permit to Construct(✓jor Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Lc PL./1I 5 3 S4- 4 t.oT,i W W Owner's Name,Address and Tel.No. (r.i-1) - -I it- 4 co 9 o Z9�( SEft'PtJ IT R\Ve-t;L a..,o L'CNNEr re A- t --I NHS ovsT� H n.ho6�S ssrCevtLA-& mA . -�7 �,. wAs+4 itia-ra" -1 -&er o2cv5'5 ✓6Cb%rcr-i , AAA. , o2i i¢ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. (So 6)- 4"L.4E-91'>I i6►rC L TC'2 ON-1r j HtiE , Ie.+L. �C P_O�.h-J[-l ro L An 1 � sTl2-e�E " Type of Building: Dwelling No.of Bedrooms S Garbage Grinder(✓j Other Type of Building No.of Persons �-•/A Showers(1,4,) Cafeteria(-/A) Other Fixtures ti a N Design Flow 1 1 o gallons per day. Calculated daily flow 55o gallons. i Plan Date G / ►a a c< Number of sheets 1 Revision Date 1� 19 2(. f Q Title PLAN o� �0 1N C�tsr ,l�arsow� ) J31A-o9.,she M.-ss � Foa V- A. r -7� C-rl_�x - Description of Soil TP I -{ o- i ' l" - 1 4-" 14f- i c" sdrun No w,�1�2 L-i-rwe-P_ 7-0 e Nature of Repairs or Alterations(Answer when applicable) JA- Date last inspected: �.4.jA 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 this d of e Signed . Date r`h Application Approved by Application Disapproved for the following reaso s Permit No. Date Issued .. ..a T...'n ._, n _rN ..; _.;�1'i{..'L.'.c1'4..... _„ .• ry.. y. ,r yit,,, .t ..,-,.,.� ,w� �-y, r..*. �,.�``'1'. jv =_ ,ram No. ih -A •Fee- 1 00 ` THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE, MASSACHUSETTS citation°for iqogar! stem' Con!gtruction Permit 71 Application is hereby triaii6 for a Permit to Construct(✓�or Repair . an On-site Sewage Disposal System at: Location Address or Lot No. ,Le RL. 1 5 3 S 4- 4 Lo T'11.d N Owner's Name,Address and Tel.No. (r,.1-i) - 't Z 1- 6t o 9 o 2�4' r�PVal , QvER QoA-1J lGNF.o 4'H A H.".seS C�y3T 2 Fiil:ahcOS� �Src7aw$LLE owA -'1-7 r-a. ti.aAs+11l_,c,roN : �EGT roc+�-r ra 0-!,+ AAA. , o i i 1 4 Installer's Name,Address,and Tel.No. : Designer's'Name,Address and Tel.No. { So S)- 4'Lrw eos,ku-�t a3� ai os T�-d.vi LLB , Mi.A,a O'2LS'S Type of Building: Dwelling No.of Bedrooms S Garbage Grinder(✓) Other Type of Building ti a- Norbf Persons t A Showers Cafeteria("/A) Other Fixtures <n w a a ; Design Flow I i o gallons per day. Calculated daily,flow '554 r gallons. Plan. Date '. 1 a 1/a C. Number of sheets I Revision Dated ,/ 8 1 2(� (g Ce Title PLA o* LA-v_jp IIy re=rt +1a1$(�e�a� ) lsac�,sra>�ar~ M,a,1 . , �rz �. A. I-1-a"p& r-r",k Description of.Soil' T-P *t i-q 1. a— P a 1-a E w r-g�-o L£`5 I 14" �aA -->E .sAti� ; 14= - 11a•' wAr�2 ,nte P_ TO e ►'1da � - 1 J11a ure of Repairs or Alterations(Answer when appl able) N/A. t'G (Date last inspected: 1 Agreement: / The undersigned agrees to;ensure.fhe construction and maintenance of the afore described on-site sewage disposal system in accordance with the pr',ovlsions+lof Title,5fof the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued'by,this d of "e i { Signed r Date 4/ ,/'7h Application Approved by J Application Disapproved for the following reaso s Permit No. Date Issued A2 1� Y4� THE COMMONWEALTH OF MASSACHUSETTS xf" t PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS Certificate of Compliance - Z Xl THIS IS TQ,CERTFY,that t e O -ste Sewage Disposal System installed(✓)or repaired/replaced( )of I } r, . by.. 'r 't fi for /t/8" SL:�tCyiT Rn1,`2 Q4e5a�D , v. ►-; . ZC't 1 � '� a t � t„p"'� as _� r s constructed in accordance with the provisions of Title 5 and't e fo�Disposal Sysle Construction Permit No. �"' ed _M01,GJ_ Use of this system is conditioned A c"ompliane iC e provisions set forth belo ' No. Fee 00 +1A' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION , BARNSfiABLE, MASSACHUSETTS Dizpogar 6peteM" Construction Permit Permission is hereby granted to to construct( .'repair( )an On-site Sewage System located at 4 P-31a-r.-P--o10_-� 0- .O�O , s t A oS r 7l�. t 1 i L Pk- !L1 a! x' C_z'1 C.Vs 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. r. l� All construction must be comp eted thin wo years of the date below. Date: Approved by o L FORM 11 - SOIL EVALUATOR FORM Page 1 of 3 Q Date: No. f41A Commonwealth of Massachusetts Massachusetts Soil Suitabili Assessment or On-site Sewa a Dis osal Date: �-......... ... -. -�.v. .......... ............ Performed B ................ Witnessed By: ..... Lion Address org �'''rct's Name. ^•��,v�� ` � Location ` ( _ Address,and C J La/ ( r✓�Q Y�P�2 8®�iS Tekphorc/ MAP 51 ?AOX-G 1T— 1 MA c>zc o New construction ❑ Repair ❑ Office Review ® C as Published Soil Survey Available: No ❑ Yes 2S � d1 R�lE2 1. ,a.... 1 Soil Map Unit Year Published Publication Scale ......'bow J E� �eew► _ ... a Drainage Class V1z •4v E0.......... Soil Limitations Surficial Geologic Report Available: No ❑ Yes Q ,.59.5 Publication Scale 1:2q�p0® Year Published Geologic Material (Map Unit) iM: J.t- C.... ..c...l......�...��c.`?...................,...............,......................... Landform +4�5 ...................................................... .......................................................................... Flood Insurance Rate Map: Above 500 year flood boundary No []Yes ® - Within 500 year flood boundary No El Yes Within o [ 100 year flood boundary NYes ❑ Wetland Area: �6Z................ ................................._. unit) ......... . ... National.Wetland Inventory Map (map ) Wetlands Conservancy Program Map(map unit ........... Current Water Resource Conditions(USGS): Month ' Range :Above Normal ®Normal ❑Belcw Normal ❑ ��Z M i:� Other References Reviewed: L=a` NOvj A ib,'"uV DEP APPROVED FORM•12/07/95 w FORM 11 - SOIL EVALUATOR FORM Page 2 of 3 Location Address or Lot No. 28 S E-pu fT Q\ \) lae- Fo-IAO C PA S L On-site Review - Time::..l2'.36 Weather Deep Hole Number Date: Location (identify on site plan) Land Use - Slope (%) " Surface Stones - E O/ 1L . :.Vegetation ��iN � Landform Position on landscape (sketch on the back) ..:::.:. Distances from: ,1'� 5� . feet Drainage way......I ... feet Open Water Body .: �f f � Possible Wet Area .. feet Property Line ..' .. feet Drinking Water Well . ...., feet Other DEEP OBSERVATION HOLE LOG* Depth from . =SoilHorizop, Soil Texture Soil Color SoilOther Surface(Inches) (USDA) IMunsell) Mottling (Structure,Stones, BoullGraveers, Consistency, �s tt ANWIP 46- tz cz cCA Qsa' l )N ® - — C c5>- ►.4 A 14 z4 '15 Parent Material (geologic) �LAGI X�L O��V�20� DepthtoBedrock: " #� Weeping from Pit Face: 1:�00C� -- Depth to Groundwater: Standing Water in the Hole.:� / p�/ Estimated Seasonal High Ground Water: ��' �V P W4Ld P DEP APPROVED FORM-12/07/95 FORM 11 - SOIL EVALUATOR FORM Page 3of3 Location Address or Lot No. 'Z 9,A �G mac' Determinatt'on for Seasonal High Water Table Method Used: ❑ Depth observed standing in observation hole........... .. inches (klon9 G� ❑ Depth weeping from side of observation hole ................. inches I-t O ❑ Depth to soil mottles .:::: . ::..: inches No help-r-Tz-F'5 ❑ Ground water adjustment ............ feet Index Well Number M.J)Kk729 Reading Date ................... Index well level Adjustment factor ................... Adjusted ground water level ............................................... Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification p °? �13 9� (date) I have passed the soil evaluator examination I certify that on ".. approved by the Department of Environmental Protection and that the above analysis PR was performed by me consistent with the required training, expertise and experience SULLIVAN described in 310 CMR 15.0111 7. N0.2IL CIVIL t4' Signature � �oaAL t V C—lo 6 1 TS -roP® 10)7=0 pF? 26 06 0 a �o V G?i TO C00 n0PW,-,-C-2 'Feo►,, �76 =22 I L EA u ►r0(- k"7 :' FAJ w\. DEP APPROVED FORM-12/07/95 15ON-Tc*tit. D 4�:® L E*4G c5 S rr I FORM 12 - PERCOLATION TEST Location Address or Lot No. COMMONWEALTH OF MASSACHUSETTS Massachusetts Percolation Test* Date: ' `� �'�' Time:. V ` ............ Observation Hole # Depth of Perc a4� -TO 641( 1 � Start Pre-soak End Pre-soak Time at 12" Time at 9" Time at 6" ". 10• Time (9"-6") N Rate Min./Inch 2 ce Mini rnurKo#- 1 .percolation test must be-performed in both the primary area AND reserve area. Site Passed �, Site Failed ❑ Performed By: -.7% -L.ty4A) Witnessed By: _�7 16�°!�1/ ��1en�5'�&-� Comments: :........................._................ . ..:.........,................. ...................... DEP APPROVED FORM-12/07/95 18. 1.0 O 0.5 / 19.0 S66 0 x 20.4 34 3j'e � 1 x 23.3 8 0.8 x 20.1 �1�' x 25.4 1► o �co '^\' � OF .FN 24.1 C B D 21.7 x 21.4 1 23.9 LOT 1NN o x 22.4 / 53,079 S,F,x 24.9 OFF . oC.B. FND. / x 22.6 1.22 AC. o' Co/R N ti 24.5 N JNOT TAN. ej� x 25.5 8. FND. � 17.7 x 2 .7 x 25. x 22.7 II (24.1 25.5 25.7 25.6 25.7 16.9 20.2 ` � 425.7 ate x x 22.2 \ el 20.0 , 17.4 I x \ 25.7!x C.B. FND 25 16.1 o N 17.8 o Q N N r. p00 Cx 22.0 x 6.5 D3 ` 15. x 18. f 01 23.5r / \ 7.6 / Ln 17. •B. FN 21. /244 U U 19.7\x 20 8 23�l3 0 20 40 80 C.B. FND. I I I scale: 1"= 40' NOTE: ALL ELEVATIONS ARE BASED ON N.G.V.D. GRAND ASSESSORS X DESIGN DATA ISLAND MAP 51 PARCELS 17 I SINGLE FAMILY 5 BEDROOMS WITH GARBAGE GRINDER N� DAILY FLOW = 110 X 5 = 550 G.P.D. LOCUS _ OTUIT SEPTIC TANK '550 X 200% 1100 BAY �. USE 2000 GAL. TWO COMPARTMENT SEPTIC TANK Lc)' COMPARTMENT #1 1100 GAL. MIN. 18 1•0 r-) COMPARTMENT 2 = 550 GAL. MIN. Ep,PO1��ER `'�' # 0 DEAD NECK 0'5 19.0 CULTEC LEACHING CHAMBER DESIGN 606 e J RECHARGER 33OR CO x 20.4 34 314e , x18 x ^':20 8 20.1 x 123.3 ALL PIPES TO BE SCHEDULE 40 PVC PERFORATED LOCUS MAP x WITH CAPPED ENDS X 25.4 _ USE 1 - 4" DISTRIBUTION LINE IN 7 RECHARGER UNITS IN A 12'X 67' WASHED-STONE-FIELD AS SHOWN SCALE 1 25,000 ,.,�' �'.- 21.4 A x `4'1 c.6. FND. LEACHING AREA REQUIRED ! i 0 21.7 x 79 �, 23.9 Z❑NrE ¢r / r 22 550 G.P.D./.74 = 743 S.F.+ 50% = 1115 S.F. o, 2(67+ 12) X 2 = 316 S.F. SIDEWALL AREA 22.4 x / x 24.9 OFF ,RP-1 & A.P. Q 54, / �_❑� `1��N 12 X 67 - 804 S.F. BOTTOM AREA g f nC.B. FND. ) x22.6 53,07E S.F. 1120 S.F. TOTAL PROVIDED ' '• W1t A a MINIMUMSco � ,22C, AREA =' 43,560 S.F. w C.B. FND. o i° n� 24.5 v FRONTAGE _20' / OT TAN. ,. 25.5 03' WIDTH = 125' DIST.so M FRONT SETBACK 30 x 2 x 25.6 SIDE SETBACKS 15 070TAL UNITS 1 STARTE14,1 END, de 8 INTERMEDIATES. I REAR SETBACK = 15' 330S TYP. 3301 33 � 0E 4, 7.5 6, 25.5 ' 6.25 BUILDING HEIGHT = 30' x 25.7 _6.25' ` (OR 2.5 STORIES IF LESS) e . 25.6 16.9 r. Z , a qpc 0� Qpo� - "25.7 II •n <e x jcy) 25.7 8 . ��' �v . 25,7 4 X . 12.00 cn 22.2 I 63'- 9 �L 17.4 x� 1 �� .B. FND 67:00' I I 25 7 C I I z PLAN VIEW 16.1 17. SCALE: 1" - 20' TQ � N I a 4 Q x 22.0 15.9 x 18. I 2 �ev� Y241 i � w \ 134/23 23.5 •- 12' I 7.6 nNISHED GIRAW COMPACTED FILL ` 17.C.B. FN 21. 2 4 s 3' MAXIMUM PEASTONE vvvvvvvvvvvv vvvvvvvvvvv BENCHM RK ::ivv viv 'vvviiv v 3/4" TO 1 1/2 " I9.7\": 20.1 5 vvvvvvv (� vvvvvvv+ vvvvvvvv vvvvvvv vvvvvvv vvvvvvv DOUBLE r lI vvvvvvv vvvvvv 0� / / 1 vvvvvv vvvvvv • WAS40 STONE 52 s 111 20.8 END SECTION C.B. FND. NO SCALE O 20 40 slCce: 1"= 40' NOTE: ALL ELEVA,,IONS ARE BASED ON N.G.V.D. TEST HOLE JUNE 18,1996 COVERS LOCATED TO WITHIN BAXTER & NYE INC. 12" OF F.G. i #P8718 ELEV. 27.5 F.G.-m 26't PIT #1 l PIT #2 26. ELEV = 25.7 ELEV. 25.5' F.G•20'f PINE NEEDLES / PINE NEEDLES z 2000 GAL INV. ' - INV. - 2 COMPARTMENT M �.� COURSE COURSE 23.0 INV �. -...�_ DrAME - - { 22.8 SEPTIC TANK INV •• T LEACHING CHAMBERS !. SAND _ SAND 22.6 [NST. SCHEDULE=4 P.V.C. ► -14" _= -14„ SEE NOTES INV. -20.0 BOX :: vvvvvv.:: INV =19.8 INV. = 1,€3.0- o 0 0 o a a o 0 0 0 0 0 -48" PERK TEST -_: -48" PERK TEST 10.00' :�$�Jv�.+cwt:wwdvJiS O O O O O O O O O O MIN. 0 0 0 0 0 0 0 0 0 0 0 COURSE COURSE BOTTOM ELEV. EL = 16.0 _-: SAND - _ SAND --Z7- PROFUS NO SCALE _. PREDETERMINED GROUND WATER ELEV. 2.0' � =- -120" NO WATER -120" NO WATER EL. = 15.7 EL. 15.5 j I CERTIFY THAT THE PROPOSED STRUCTURE SHOWN - OF P L-[IT - : PLAN ' ❑F L LAND T1 HEREON COMPLIES WITH THE SIDELINE AND SETBACK { of f 1 1J REQUIREMENTS OF THE TOWN OF BARNSTABLE, AND '`�r�� . , a��c SULLIVAN ' IS NOT LOCATED WITHIN THE FLOODPLAIN. ;o WILLIAM yr N0.29733C. �„ IN N Y E cli� CIVIL (OYSTER HARBORS) 2.0 -� C ,p No. 19334 O 9FalST�Q� BARNSTABLE MASSi FOR -NOTES NOTES: KENNETH A. & JODY R. HINES D FOR ALL ASPECTS OF THE SEPTIC SYSTEM THE CONTRACTOR (1) REMOVE UNSUITABLE SOILS E'SNEATH PROPOSED SYSTEM BACKFILL SCALE: AS NOTED DATE: JUKE 11 8,1 �516 y ` SHALL COMPLY WITH ALL GOVERNING CODES AND REGULATIONS. WITH CLEAN GRANULAR MATERIAL FILL TO BE GRADED AS FOLLOWS: NOT MORE THAN 15% RETAINED ON No. 4 SIEVE, NOT MORE THAN 907. RETAINED REV,: J U L Y 18,19 9 6 REV,: J U L Y 2 5,19 9 6' IN PARTICULAR 310CMR 15.000 THE STATE ENVIRONMENTAL CODE TITLE 5, ON No. 50 SIEVE, OF FRACTION PASSING No. 4, 10% OR LESS TO PASS, No, _ a THE TOWN OF BARNSTABLE BOARD OF HEALTH REGULATIONS PART VIII: 100 ENGINEER A D 5%C R LESS TO'PPPASS TONo. 200INE SIEVE, SITE.TO BE APPROVED REV,: AUG.G; 2,19 9 6 �N u I $-02 ON-SITE SEWAGE DISPOSAL REGULATIONS AND THE BOARD OF HEALTH RECOMMENDATIONS FOR ACCEPTED PRACTICE. B A X T E R & N Y E INC, (2) LOCATION OF UTILITIES NOT SHOWN ON THIS PLAN, AT LEAST 72 HOURS O2 TWO COMPARTMENT SEPTIC TANK REQUIRES 2 WEEKS OF LEAD TIME PRIOR TO ANY EXCAVATION FOR THIS PROJECT CONTRACTOR SHALL MAKE REGISTERED LAND SURVEYORS THE REQUIRED NOTIFICATION TO`DIG SAFE (1-800=-322-4844) AND APPROPRIATE TO ORDER FROM SUPPLIER. WATER DISTRICT TO DETERMINE UTILITY LOCATIONS. CIVIL ENGINEERS 03 THE SEPTIC TANK'S FIRST: COMPARTMENT SHALL BE SIZED FOR 1100 GALLONS MIN. ❑S T E R V I L L E, MASS, THE SECOND COMPARTMENT SHALL BE SIZED FOR 550 GALLONS MIN. {',. ALL IN ACCORDANCE WITH 31OLMR 15.224 MULTIPLE COMPARTMENT TANKS. TWO TANKS IN SERIES MAY BE SUBSTITUTED SUCH THAT°THE FIRST TANK IS 1500 GALLONS & THE SECOND TANK IS 1000 GALLONS AS PER 15:225. #96074-1 2