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HomeMy WebLinkAbout0080 SEAPUIT ROAD - Health 80 Seapuit Road y • Osterville P A = 118 136 47 ° , e , • ,. of , e o o _ r Commonwealth of Massachusetts �. Title 5 Official Inspection Form 1, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 80 Seapuit Road ! ' Property Address - Theresa Garrett Owner Owner's Name -* information is €osterville MA 02655 09/15/2020 required for every _ page. City/Town State Zip Code Date of Inspection G;1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road Co � Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails t Inspectors Signature7 Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Seapuit Road Property Address Theresa Garrett Owner Owner's Name information is Osterville MA 02655 09/15/2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This home has 4 bedrooms in main house and 1 bedroom in pool house. The system has an H-10 1500 gallon septic tank with an H-10 D-Box feeding 6 flow diffussors. At the time of the inspection no visible failure criteria was found. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is'structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Seapuit Road Property Address Theresa Garrett Owner Owner's Name information is required for every Osterville MA 02655 09/15/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed' ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form l� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 80 Seapuit Road Property Address Theresa Garrett Owner Owner's Name information is required for every Osterville MA 02655 09/15/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt*marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts 60 Title 5 Official Inspection Form rile Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............., 80 Seapuit Road Property Address Theresa Garrett Owner Owner's Name information is required for every Osterville MA 02655 09/15/2020 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ` ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Seapuit Road V� Property Address Theresa Garrett Owner Owners Name information is required for every Osterville MA 02655 09/15/2020 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I Commonwealth of Massachusetts �n = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments I 80 Seapuit Road Property Address Theresa Garrett Owner Owner's Name information is required for every Osterville MA 02655 09/15/2020 page. CitylTown State Zip Code Date of Inspection D. System Information 1. 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 plus GPD Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage town water 9 ( Y 9 (gpd))� Detail: In 2019-33,000 gallons were used and in-2018-19 000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u- 80 Seapuit Road Property Address Theresa Garrett Owner Owner's Name information is required for every Osterville MA 02655 09/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form lip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .V 80 Seapuit Road Property Address Theresa Garrett Owner Owner's Name information is required for every Osterville MA 02655 09/15/2020 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 32"feet Material of construction: ❑ cast iron ®40 PVC 2 pipes ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed from the pool house and the home and it came freely. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Seapuit Road Property Address Theresa Garrett Owner Owner's Name information is required for every Osterville MA 02655 09/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 24°feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: H-10 1500 gallon Sludge depth: 5' Distance from top of sludge to bottom of outlet tee or baffle 31" ` Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge 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 recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts �n a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Seapuit Road Property Address Theresa Garrett Owner Owner's Name information is required for every Osterville MA 02655 09/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass '❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 ' Commonwealth of Massachusetts Title 5 Official Inspection Form .1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Seapuit Road Property Address Theresa Garrett Owner Owner's Name information is required for every Osterville MA 02655 09/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): " Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 r Commonwealth of Massachusetts �- Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t,— 80 Seapuit Road Property Address Theresa Garrett Owner Owner's Name information is required for every Osterville MA 02655 09/15/2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 6 Flows ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 80 Seapuit Road Property Address Theresa Garrett Owner Owner's Name information is required for every Osterville MA 02655 09/15/2020 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/16/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 I Commonwealth of Massachusetts �n Title 5 Official Inspection Form l� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Y Y >r� V � 80 Seapuit Road Property Address Theresa Garrett Owner Owner's Name information is required for every Osterville MA 02655 09/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts g Title 5 Official Inspection ",Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Seapuit Road Property Address Theresa Garrett Owner Owner's Name information is every Osterville re tired for eve 'MA 02655 09/15/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately .ssessing As-Built Cards https://townofbamstable.us/Departments/Assessing/Property Valu... TOWN QF BARNSTABLE. LocAwerr—&0 Scgoutif Rcl. SEWAGEM 9 Fr-?03 VILLAGE omrv.l1L ASSESSORS MAP&LOT//8'- /3/D INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILrrY:(type)(0- Pow 11 t•i rayou `(size) laX'/y NO.OF BEDROOMS SS I 1 BUILDER OR OWNER [�►ry SlDoha/ l.t l t an PERMITDAM COMPLIANCE DATE: Separation Distance Between dm: MwdmumAdjuatedOmndwataTabletotheBottomofLeachingFaeility FOOL Private Water Supply Well and Leaching Facility(If any wells exit on site or widlin 200 feet of leaching facility) . Feet Edge of Watland and I eaching Facility(If any wetlands exist within 300 feet of leachiu8s�facility) Feet Furnished by L�/ITD¢yfian re,2 A B I /7 3f s 61515i a3 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 80 Seapuit Road Property Address Theresa Garrett Owner Owner's Name information is required for every Osterville MA 02655 09/15/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 10 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u� 80 Seapuit Road Property Address Theresa Garrett Owner Owner's Name information is required for every Osterville MA 02655 09/15/2020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 No. a U o q .2 Fee 10 a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 't Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpplication for Zi.5pogar bpgtem Construction Permit Application for a Permit to Construct( )Repair(�O Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. 70s 6A�fV CV Owner's Name,Address and Tel.No. C, P S AV✓S Assessor's Map/Parcel Ii 3! (vl staller's dd an Te Designer's Name,Address and Tel.No. s�o- 07 Type of Building: I---*- Dwelling No.of Bedrooms .J Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil M of Repairs or Alter do (Answer when)aplicable) r10&J POO V gL v Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance the afore described on-site sewage disposal system in accordance with the pro ' ' ns of Title o r nme od nd not to place the system in operati4untilcate of Compliance h e e o lth r Sed Date Application Approved by Date Application Disapproved for following reasons Permit No. ow la LI '2 Date Issued - No. d o o-1 Fee too , — THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS a. rication for iq ogal 6potem Construction Permit Application for a Permit to Construct( )Repair Upg ade( )Abandon( ) ElComplete System El Individual Components i Location Address or Lot No. seAeve Owner's Name,Address and Tel.No. ng Assessor's Map/P �el'I nstaller's a dd s,and Te Designer's Name,Address and Tel.No. o j w Sod /v /T Type of Building: .i•'" Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) fr Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date t Title Size of Septic Tank Type of S.A.S. Description of Soil Natqm of Repairs Alt do (Answer when a plicable) /'�C '13 N I O e )G < < Date last inspected: �f Agreement: The undersigned agrees to ensure the construction and maintenance the afore described on-site sewage disposal system in accordance with the pr x 'off Title 5 o e r� in od nd not to pace the system in operation until Ce ifi- cate of Compliance h be ed by-th' o alth St d Date Application Approved by n.. Date ,S / L/ Application Disapproved for t following reasons Permit No. ra a y Date Issued L� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE_R� t th n-s' S'e ispo al System Constructed(X )Repaired ( ) Upgraded( ) Abandoned( )by 7-4 at �A v� —C Hq0 PL'OnJ2 has been constructed in,accordance with the pLoy i .o_fjTjitleS.and tl fgr Dispos 1ySy�tem Construction Permit No. Oo "23 dated 121611 Installer j<- Aj S � V C�-i P'a,? Designer Il-� The issuance of this ermit shall not be construed as a guarantee that the s will f n tion asLsigneL(/./ Date 5 r(�j Q<< Inspector 1` l t 00 No. aLUC)H - 23 6 Fee � � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS f Migo.5afl*p5tem Construction Permit Permission is hereby granted to Construct( _)Repair( ) e( )Abandon 8 ( ) System located at 0— .S,6A�P d i�l _ and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constru tion Inust be completed within three years of the date of t 's p t . Date: "�/ Approved b - �— PP y COMMONWEALTH OF. MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION F CEIVED 2 12002 TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM ' NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 80 Seapuit Road Osterville, MA 02655 Owner's Name:. Christopher Caton Owner's Address: Same Date of Inspection: November 2, 2002 Name of Inspector: (Please Print) James M. Ford Company Name: James M..Ford Mailing Address: P.O. Box 49 Map: 118 Osterville,MA 02655-0049 Parcel: 136 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 urther Evaluation by the Local Approving Authority ails Inspector's Signature: Date: November 3, 2002 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 I I 1 a Page 2 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 80 Seapuit Road Osterville, AM Owner: Christopher Caton Date of Inspection: November 2, 2002 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 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 80 Seapuit Road Osterville, AM Owner: Christopher Caton Date of Inspection: November 2, 2002 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 M 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 aseptic 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 4 \ Page 4 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 80 Seapuit Road Osterville, M4 Owner: Christopher Caton Date of Inspection: November 2, 2002 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 '/i 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 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 11 CHECKLIST Property Address: 80 Seapuit Road Osterville, MA Owner: Christopher Caton Date of Inspection: November 2, 2002 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,aplan 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)]. I I 5 • Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE_ SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 80 Seapuit Road Osterville, AM Owner: Christopher Caton Date of Inspection: November 2, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 5 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 3 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required_ ] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): end 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: Never pumped-per owner Was system pumped as part of the inspection(yes or no): No If yes, volume pumped: eallons-=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: Dec. 28198 -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: 80 Seanuit Road Osterville, 1U Owner: Christopher Caton Date of Inspection: November 2, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Approx. 36" . Materials of construction: _cast iron ✓ 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: Approx. 22" 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: 1500 gal. Sludge depth: I" Distance from top of sludge to bottom of outlet tee or baffle: 30' Scum thickness: 5" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 10" 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.): r Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. Recommend installing risers. 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 A • Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 80 Seapuit Road Osterville, MA Owner: Christopher Caton Date of Inspection: November 2, 2002 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 car yover,'any evidence of leakage into or out of box,etc.): The D-box was level and clean. There were no signs ofsolids. There were no signs of backup or failure in the leach field. PUMP CHAMBER: None locate on site plan) ( P ) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 80 Seapuit Road Osterville, MA Owner: Christopher Caton Date of Inspection: November 2, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why:. Type leaching pits,number: ✓ leaching chambers,number: 6 flow diffusors- 12'x 44'(per as built card leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system" Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): The flow diffusors were located but not dug up. There were no signs of backup in the D-box. The bottom to,grade was approximately 7. 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 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 80 Seapuit Road Osterville, MA Owner: Christopher Caton Date of Inspection: November 2, 2002 Map: 118 Parcel: 136 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. 17 17 3/ a �� 39 g� Fro„, P 32 SI � 3 I 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION (continued) Property Address: 80 Seapuit Road Osterville, MA Owner: Christopher Caton Date of Inspection: November 2, 2002 SITE EXAM Slope. Surface water Check cellar Shallow wells Estimated depth to ground water 35' +/- 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: The bottom of the leach field to grade was approximately 7. Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 35'+/-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 and/or this report. 11 4 No. i)-q a= Fee-- BOARD OF HEALTH TOWN OF BARNSTABLE 0(pplicationforlVell Con5truct ion Permit Applic ti hereby d for a p it t C nstr,4ct ter or Repair ( )an individual Well at: a 1011 is y�n 4- Location fAddress Assessors Map and Parcel 0 Address S .07 ( ---- ap Installer Driller Address Type of Building Dwelling Other - Type of Building No. of Persons-------------- Type of Well Capacity----y Purpose of Well Agreement: The undersigned agrees to install the aforidescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation unti Certi e has been issued by the Board of Health. Signed- —6; d t Application Approved By 7 Jate Application Disapproved for the following ----—---- date Permit No. Issued - -7 kla ,7 date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS 'S�T�PErIRTI Y, That the Individual Well Constructed W), Altered or Repaired by--- Installer has been installed In accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE Inspector No. 1j 1jo3-=3a Fee-------` -------- c, - - : BOARD OF HEALTH . TOWN OF'' BARNSTABLE application-*f Vell Cootruct ion Permit f .r Applic tIon,is hereby made for a pe it t C nstruct (G)'Alter ( ), or Repair ( )an individual Well at: --- 1 - 4 - -- ? r Location'=;,Address, r Assessors Map and Parcel Owner Address s2D �"G!J --:,--------- --� �---------- ----�,fox_�3� . Installer — Driller Address Type of Building i Dwelling - " Other�- Type of Building No. of Persons--------------------------- -- Type of Well{ � ��_--_—_ Capacity--- '�� --- — Purpose of Well------ ':----- .'- Agreement: r The undersigned agrees to'install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to } place the well in operation until a Certi -at V fi -m it a has been issued by the Board of Health. Signed ---------------- --to date Application Approved Byj�` _ �=-_—___— /D --_- �` F ate Application Disapproved for the following reasons: ----- --- --- -- ---- -- r - —------/ u- __-—-- -- ------ — date Permit No. d 3 -- __—____ Issued --- - ----- — —----------- + date -A�-=..e—_.-,.�-•`--n�-a�:—.:r--a�-.--•_ ---�-�.--�.-_.-._. ---•-- .-,—�--�—c-«e----'�.'r�--T-.;•_-k.- .. _.. - _ _ -. _ _"_,- _ -n...�,....._ _ _ _.Lam. _�;_.-,-._mom'-�-..�._.., r.... ..- - - BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of COMPliante k THIS IS TO ERTI�Y, That the Individual Well Constructed X), Altered ( ), or Repaired by ( ) --- --- ----------------------------------------- - ---- -- --------- ------------ -- I Installer ------ has been installed In accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. tin '=- Dated - ?----- ' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE- ---- --- —- Inspector------ - - - -- -------- BOARD OF HEALTH TOWN OF BARNSTABLE )pelt (Con$truct ion Permit No. - -"� U d 3= 3 Fee Permission is hereby granted --_ to Construct V), Alter ( ), or Repair - ) an Individual Well at: ,� �, M 1L� --------------------------------- No. — �— - as shown on the application for a Well Construction Permit No._-1 U O _�� — — Dated-� - ---- -------------------- Board of Health DATE � I NJ taq f2.q8 0 , 43 OF \�� �ovrJepT-rpN �\ ,�� �• , o � I o ;. I m I42 S � vo 24048 ,t '' 40 LAW rvwr OL07' F�lAAI i L0CA rlC I D5 r2F)Z //!4G 7-1-IA 7- THE rovAt as riod i S,�iOl�ciiv,yE.eEO�(/ C0�1�L YS Gr//Th' ScA L-G— as 0•�1 T� aEC Z 31�5%g �EQ!/ieE�1e7rS. O� Tf/E Tow�t/OF i t3A enl sTA 04Z- /S /JOB LDT 4-3 7 XZ-5 - Goa�PG4/.f! L G. G . S7ZS - S I �.4 TE= ?'?3' B 4 X7.E, �.C_I,v/S Ic/oT B,4SE�O dc/.4�f/ .AEG/STE.eF� L.4�/p SUeG��Y c . /�VST,e!/�-/Eit/T,SUS✓EY� Tl�� OSTE,21i/,C.,C��' �'1%SS. O -�SET-S sh�o�,✓y Ss�vc� .t/oT f Z4✓AZ4 G"4 Tc N j U,SEp Tp OET�.P�f/NE ,LOT L/DES ----_ b� �'D, bo,If-)L;11' '7 9D'4 / aad fl-A ff 919 vr T-V OW 4 ----------------------------- ----------------------------------------------------- —--- -------------- • F --- U P vs • 24 x I 54 a NET BAR/ 5 k EATING4 x --------------------------------------- ---- ---- --------------------—------------------------- lip "kLL;; bxo PM m STORAGE • STORAGE IMF Ix VVAP L*FIM*W 2-6 LO X 3�I 912N 74 &Ab PMT ry Ix FWAF ----------------------- ---------------------------- --------------------- 104M 2-6 X ACIM56 TO ENTRY LIVING 101!E 4 424ft t" 3 VT 610 PMT#V LK raw -------------------------------- --- --------------- ---------- ----------------------- - ----------- PORCHSTORA&E VEOUW Lwnslev ON P.T.2X FR4C ------- ------ ---------- --------- tr M& Co- ........ 917 914' Lm- v 7.01 T-W 416' Wd 27-V S T r- L 0 0 R P L N E C 0 N 0 F L 0 0 R P L A N C A L S I / 4' 1 0 5 C: ALE, I/ 4 TOWN OF BARNS T ABLE LA-7-OCG!;JZ2V '1�3 S�!� Ut f R-0- SEWAGE # 0 ,7 6 3 VILLAGE C "�rui r, IS A r A J ASSESSOR'S MAP & LOT Ask INSTALLER'S NAME&PHONE NO. PORV e,Q y 1L�i i tilG 'Z'7 N SEPTIC TANK CAPACITY 4J �- i I LEACHING FACILITY:. (type)�8,- �.L),{&4E7 z/ (size) )L x qq v NO.' OF BEDROOMS ;.;BUILDER OR OWNER PEkMrTDATE: t6l — , aG COMPLIANCE DATE: Q<9 .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 �: �- `_ ��_ �''i, . .'� i I _e �, s®��� � �`. / � � 3� TOWN F BA.RNSTABLE LOCAz'ION O SG 0t /JC-• SEWAGE # 0 ' 3 VILLAGE d meru, A ASSESSOR'S MAP & LOT t INSTALLER'S NAME&PHONE/NO. SEPTIC TANK CAPACITY l S� LEACHING FACILITY: (type) G POLO 1� (size) pax 415 NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching1facility) Feet Furnished by /1S,DeA,o� � �0� Alp- pro,,i � 3 Fee ° THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: . es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zpprication for Zigonl *p5tem Cou.gtruction Permit Application for a Permit to on tntct O Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address o1no No. L�` Cj J��" �, �I�C4�iSe 4 tl- La4.t�ak et4TOIJ Assessor's Map/Parcel a�'��f l 'I J6,1 AAA1_-r1 6,A L-& Installer's Name,Address,and Tel.No. Designer's .,Address and Tel.No.nd Type of Building: Dwelling No.of Bedrooms Lot Size 1 1 © sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow C-)O gallons per day. Calculated daily flow `3 SD gallons. Plan Date M-r 14-+ 14gt Num er of sheets Revision Date Title rw �LAo BP�143 tN �STtw11 ' `'kQ l$ `�2 G0� 4l +-Lain PA` hi Size of Septic Tank ISDo ------Type of S.A.S. LJ5ACo�t?� 1[�t�-1 Description of Soil -'3" D AIL Its`� My 10- j ra op `I %30I om S A NC, IOyir S) Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu y thi B ow d Health. l Signed Date Application Approved by Date AT-30'�� Application Disapproved for the following reasons Permit No. y Date Issued /40 -3Q'-,91 4:5- J ..� No. �O — �.,.. - I 40= -;: .t Fee t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION 'TOWN OF BARNSTABLE 'MASSACHUSETTS 2pprication for Mi-qpo!6af�*pztem Conotruction'Permit h Application for a Permit to Construct X)Repair(: )Upgrade( )Abandon( )�❑Complete System ❑Individual Components Location Address or Lot No. ame,Address and Tel.No. ujA- ct els 4 LAVa t CAT00 Assessor'sMap/Parcel (i k IG,L AAAZI-11 AG6 "&MAP '.���- �86 00 Installer's Name,Address,and Tel.No. �i�,. f:J Designer's Name,Addre s and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size i O2 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures MiSwvr \Design Flow `J� gallons per day. Calculated daily flow 5 SD gallons. Plan Date Oct- 14-,lciq$" Numpp-er of sheets ( Revision Date Title sett AW or-Ldr'143 IN It�SYE:2all l RN4�1�3ta, 2 Aw115 + ?.a t�Tb Size of Septic Tank I SM Type of S.A.S. t.L—_AGa4I Wo 6 AI.L.6-1 Description of Soil 0-3" O, r��i I6''�i !Q' -� `$. ?- �11 M 1 tJW� S A 1J� 1051R. OL ,f Nature of Repairs or Alterations(Answer when applicable)"^ a Date last inspected: a 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 issu7=d ealth. Signed Date a f /9 Application Approved by Date Application Disapprovedfor the following reasons f Permit No.r 7 70 Date Issued - --------------------------------------- 1 THE COMMONWEALTH OF MASSACHUSETTS - BARNSTABLE, MASSACHUSETTS I° .f' °certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(lC)Repaired( )Upgraded( ) Abandoned( )by. ` at S 1T"' Vio DS LlL tit t...t..'e� has been constructed in accordance with the provisions of Title 5 and the for Disposal System.Construction Permit No. ` 70-3 dated /d"3 CI—9 Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date 1 -1.. 1i Inspector No. / Lf--7—0-7 --------------------------Fee /W THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwizpool *pztem Conotruction Permit Permission is hereby granted to Construct( Y�Repair( )Upgrade( )Abandon( ) System located at fie- 1 4% stsA F*o lm__-T .d 0 -rear /1 C i and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three,years of the date of this'n' •t. '? Date: � �/`7 Approve y..� TOWN OF BARNSTABLE —7 LOCATION Lei y� d, �t�- SEWAGE # � /G dII LAGS _ 9l"C�i ASSESSOR'S MAP& LOT13 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACII.TTY: (type) ,_��l,2� (size) NO.OF BEDROOMS f BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: .�L 919 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 - -------- .............. f I i _ I Town of Barnstable I'# `� �S ✓ Department of Health,Safety,and Environmental Services f IM Public Health Division Date 06T' 367 Main Street,I lyannis MA 02601 BARNBTABM MASS rEot��� Date Scheduled �C . � '� — f Time Fee Pd. No Soil Suitability Assessment for Sewage Disposal Performed By: Witnessed By: V t"">�21Lv1 J13 1�IS 1A1� LOCATION & GENERAL INFORMATION /' Location Address SO 5 �� 1 fi- Owner's Name 0141 Cq� <4A s _Toti t7T At j t.4-t WI�Q"dam' �R- �`��� Address Pl-q✓N 00 rbL Assessor's Map/Parcel: MAP 1113 P&L_ 13`p Engineer's Name `g A-eTWL,4- NEW CONSTRUCTION V( REPAIR Telephone# A-`Zb ^ ql� Land Use Slopes(%) O Surface Stones Distances from: Open Water Body ft Possible Wet Area 2S'*0 ft Drinking Water Well '500 fl Drainage Way ^— R Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) o l AI i /N 4 � 2 N 142— I 4 t-r Parent material(geologic) OdPrW-All w Depth to Bedrock �— Depth to Groundwater: Standing Water in Hole: a'OP3IC� L Weeping from Pit Face Estimated Seasonal High Groundwater I3E TEN ATIOl�i FOIr SEASONAL.HIGH WATER TABLE Method Used. �✓ Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level_ J PERCOLATION TEST Date/0 >,� '`Time Observation Hole# Time at 9" Depth of Perc �PJ Time at 6" Start Pre-soak Time @ nVA)46fLT-_U SArV17A4T Time(9"-6") End Pre-soak Rate Min./inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back--j Copy: Applicant -71 l' — \ DEEP.OBSERVATION HOLE LOG Hole# / Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes. Consistency,o LOAMY' 0 ,5-R -5�0>� 0 DEEP OBSERVATION IIOLE LOG Hole# 2 Depth from Soil Horizon Soil Texture I Soil Color I Soil I Other (USDA) ( Surface(in.) Munsell) Mottling (Structure,Stones,Doulderes. 0 tr o C) I � I DEEP OBSERVATION HOLE LOG Hole # Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Doulderes. Consistency.%gravel l i i DEEP OBSERVATIONHOLE LOG' Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other j Surface(in.) (Munsell) Mottling (Structure,Stones,Doulderes. Consistengy.°o Gravel) i i I Flood Insurance Rate Man: i Above 500 year flood boundary No_ Yes i Within 500 year boundary No Yes Within 100 year flood boundary No Y Yes 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 1 certify that on /Q (date)I have passed the soil evaluator examination approved by the Department of Envi onmental Protection and that the above analysis was performed by me consistent with the required uired training,expertise and experience erience described in 310 CM R 15.017. Signature Date N iCEVALLEYRO o Z� � U1S R sEP TEST HOLE #1 -TEST HC)LE 2 ST. MARY S S COVERS LOCATED TO WITHIN P-7254 P-7254 6 OF F.G. BAXTER & NYE INC. BAXTER & NYE INC. ISLAND gA� S�_ F.F. ELEV. = 46.0 OCT. 13,1998 OCT. 13,1998 BLUE HERON DR. F.G.= 44'f F.G.= 43't ELEV. = 43.5' NORTH F.G.=44' ELEV. = 42.3' O BAY LEVEL INV. = 1500 GAL 4" DIAMETER TEE 2 ¢ LOAMY SAND-E 10YR.3 2 ! LOAMY SAND-E 10YR 32 LOCUS MAP 42.© INV. - LEACHING CHAMBERS „ / -10" / 41.8 SEPTIC TANK INV. = DIST. SCHEDULE 40 A.y,C t -10 SCALE 1 25,000 41.6 INV. =41.4 eox SANDY LOAM-B 7.5 4YR 5 g SANDY LOAM-B 7.5 YR 5/8 ASSESSORS _ .,....,.,,., .: INV. =41.2 INV. = 41.0 / -24" w4 10-00' "' .. --6" STONE BASE-�"�-' -24p MEDIUM-C 10YR 7/3 MAP 118 PARCEL 136 MIN. •„ !� .� MEDIUM-C 10YR 5/6 SAND SAND -48" PERK TEST BOTTOM ELEV. EL = 39,0 -48" PERK TEST GRAPHIC SCALE 0 40 80 it - --� . . . EL. 33.5'-120" ZONES PROFILE wlP NO -SCALE EL. 31.3'-132" RF-'I NO WATER MINIMUMS AREA = 43,560 S.F. FRONTAGE = 20' WIDTH = 125' FRONT SETBACK = 30' SIDE SETBACKS = 15' REAR SETBACK = 15' BUILDING HEIGHT 30' DEMN DATA SINGLE FAMILY- 5 BEDROOMS 6m TOTAI UNITS; 1 STARTER,1 END, & 4 INTERMEDIATES. 12'FINISHED GRADE NO GARBAGE GRINDER 2.6 3305 T s.25 01 s3252.65 36 MAX.- 12 MIN. � �\ \' r /� /� \ M\// > Cfl14IACTED FILL DAILY FLOW =' 110'X `� = 550 G.P.D. 2„_� \ \ \ \ \ \ \ \ \ PEASTONE SEPTIC TANK 550 X 200% = 1100 4. USE 1500 GAL. SEPTIC TANK 0 30.5" _ •. 0 ° . 3/4" TO 1 1/2 " • • � ,, DOUBLE CULTEC iEA HING CHAMBER DESIGN . WASHED STONE 1-1.5" WASHED STONE f IRECHMMER a 3OR OR Fi% AL�iNT �---- 44"00' ALL PIPES TO BE SCHEDULE 40 PVC PERFORATED PLAN OF LEACH TRENCH WITH CAPPED ENDS SECTION USE 1 - 4" DISTRIBUTION LINE IN 6 RECHARGER UNITS SCALE: 1" 20' IN A 12'X 44' WASHED STONE TRENCH AS SHOWN NO SCALE LEACHING AREA REQUIRED 550 G.P.D./.74 = 743 S.F. 2(44 + 12) X 2 = 224 S.F. SIDEWALL AREA (12 X 44) = 528 S.F. BOTTOM AREA 752 S.F. TOTAL PROVIDED SOIL CLASS I PERC RATE < 5 MIN./INCH 0 21 C.B. S FND. OFF �� 6 M� MPR� P• P ,�,,� 29.0 33.3 2 J 4 h ~ N69 x 37.5 x�36 .-- G.6 3 ' `, x 35.5 x 4 � rn -' L " 12• , i ' is r ,3' -,-,,x 39.6 -A x rev x 41.0 x 41.70 4� f, x 341 0 % x9.9 r /� i 14A 5 N o X 41.1 LOT co }l Q 3 CD D x 42.00 W 01 43.3 o70 z x41.5 x43.2 x40.5 x43.3 x 0 � x 42.7 00 r j-- r LOT 143 N x 41.10 x 43.3 x 39.1 ' DECK x 43.3 � 117,025 S,F, x 40.8 2,6 9 A c,s x 41.4 � f x 41.0 Jr �_ d �IN / A500 ^'At nIST. i V) ti �Z i PROPOSFA HOUSE T BOX x 39.50 �"J \ I x 42.2 n J x 42.9 � �/'f -'` PORCH z / GA0 x 43.4 Q 2.3 x 39. / f 2.6 �a x 43.0 3� . 4 + 42.3 x 44.2 �, 42.i 1 x.-441J i x 42 5 BENCHMARK O r, # / - * -� --``_........,may'' TOP OF BOUND x�.38 0' ��� x 38.40 1 43.5 \ -►1 EL. = 43.63' U Ip h 1 1 O E 42.4C.B. (j �lS I,I x 49.70 Qj ,� 1 #2 x J 44.5 .43.6 FND. x 37.30 ! i7 x .1 43.7 x 37.60 `j C.B. 41. 27 3,` 2 1 x 37: .0/ x 37.0 ,. 42.10 � / 4.2 ELEVATIONS ARE BASED ON N.G.V.D. "�- x 44.4 C.B. BENCHMARK - FND. TOP OF BOUND /x -- 44.00' x 43.5 x 36.70 EL. x 43.0 3 32 LOT 142 2,8 % 2 .2 3. 0 2 x 23.50 � - �� x 29.2 IAJ Vo ti M / M x 27.6 SITE PLA14 OF LOT 143 0 X 2 of x ft�s �-� - L.C.C. 5725-51 ! IN PLAN �'`- �o .40/ / (OSTERVILLE) 11 BARNSTABLE � MASS. SCALE: 1" = 40' '�'2� 1. THIS PARCEL iS NOT LOCATED IN THE FLOOD PLAIN.1334 FOR 2. REMOVE UNSUITABLE SI'ILS BENEATH PROPOSED SYSTEM, BACKFILL x 34;90 ( / WITH CLEAN. GRANULAR MATERIAL FILL TO BE GRADED AS FOLLOWS: NOT CH RI LA BRA CATON MORE THAN _15% RETAINS-D ON No. 4. SIEVE, . NOT MORE .THAN 907 RETAINED H (� --- ' 3 ON No. 50 SIEVE, OF FRACTION PASSING No. 4,. 10%.OR, LESS TO PASS No. --__ 6 100 SIEVE AND 5% OR LESS TO _PASS No 200 SIEVE, SOIL TO BE APPROVED SCALE: AS NOTED DATE: OCT. 14,1998 BY ENGINEER FOR COMi _IANCE PRIOR TO PLACING ON SITE. So. BAXTER 8� NYE INC. . 8 2 3. LOCATION OF UTILITIES NOT SHOWN ON THCS PLAN, AT LEAST 72 HOURS REGISTERED ..LAND. .SURVEYORS x ._ PRIOR TO ANY EXCAVA ON FOR THIS PROJECT CONTRACTOR_SHALL MAKE CIVIL ENGINEERS 39.00 THE REQUIRED NOTIFICATION TO DIG SAFE (1-888-344-7233) AND APPROPRIATE N71`19:, WATER DISTRICT TO DETERMINE UTILITY LOCATIONS. jN OF 61g ❑STERVILLE, MASS. xU 9.51}3�1' STEPHEN yG Of YNROW � SM 4l0. 02t6 A. ,. � BAXTERa Ss1G`r Al EN '�'p LIIO I #98111 t