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Home My WebLink About0170 SEAPUIT ROAD - Health I:7,0,SEAPUIf,ROADY• I 5a Osterville A`= 095'—'02'52 e a d Y a y j 1 Massachusetts 025- oal,� co Commonwealth of Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ell 170 Seapuit Road Property Address f �7 Peter Bentivegna Owner Owner's Name / � information is Ostery required for every ille MA 02655 September 5, 2019 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. Inspector Information filling out forms on the computer, Patrick T. Sullivan use only the tab key to move your Name of Inspector cursor-do not Ready Rooter Excavating use the return Company Name key. PO Box 89 Co � Company Address Forestdale MA 02644 CityfTown State Zip Code 508-509-0802 S112843 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 16.000); 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, September 12, 2019 Inspe ors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doe•rev.7/2 61201 8 Title 5 Official Inspect on Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 170 Seapuit Road Property Address Peter Bentivegna Owner Owner's Name information is required for every Osterville MA 02655 September 5, 2019 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: ® 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: 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 termined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and o r 20 years old" or the septic tank(whether metal or not) is structurally unsound, exhibits substantia nfiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing to is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank w'I pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicatin that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/2 612 0 1 8 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 170 Seapuit Road Property Address Peter Bentivegna Owner Owner's Name information is Osterville MA 02655 September 5 2019 required for every P page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced, ❑ Y ❑ N ❑ ND(Explain below): • ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is le eled 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 R/requifurther Board of Health: ❑ Conditions exist whier evaluation by the Board of Health in order to determine if the system is failing ic health, safety or the environment. a. System will pasd of Health determines in accordance with 310 CMR 15.303(1)(b)that tht functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/2 612 01 8 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments > 170 Seapuit Road Property Address Peter Bentivegna Owner Owner's Name information is required for every Osterville MA 02655 September 5, 2019 page. Cityrrown 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 a SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS d the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SA 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 nalysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent an the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that o 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 El ® 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 I c Commonwealth of Massachusetts _ Title 5 Official Inspection Form p� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 170 Seapuit Road Property Address Peter Bentivegna Owner Owner's Name information is Osterville MA 02655 September 5 2019 required for every P , page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow El ® 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 CM 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 syst is within 400 feet of a surface drinking water supply ❑ ❑ the sy tem is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the ystem is located in a nitrogen sensitive area (Interim Wellhead Protection Ar a—IWPA) or a mapped Zone II of a public water supply well --V.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 ,w 170 Seapuit Road Property Address Peter Bentivegna Owner Owner's Name information is p required for every Osterville MA 02655 September 5 2019 page. City1rown 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 a/f 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.7/2 6120 1 8 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,. 170 Seapuit Road Property Address Peter Bentivegna Owner Owner's Name information is Osterville MA .02655 September 5, 2019 required for every P page. Cityrrown State Zip Code Date of Inspedion 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): 621 GPD Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ® Yes ❑ No If yes, discharges to: Septic tank 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 2017=476 GPD Water meter readings, if available (last 2 years usage(gpd)): 2018=419 GPD Detail: Sump pump? ❑ Yes ® No Last date of occu anc : Current P Y Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 170 Seapuit Road Property Address Peter Bentivegna Owner Owner's Name information is p required for every Osterville MA 02655 September 5, 2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: �I Design flow(based on 310 CMR 1.5.2 ): Gallons per day(gpd) Basis of design flow(seats/person /sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit presen ❑ Yes ❑ No If yes, dischar es to: Industrial waste holdin ank present? ❑ Yes ❑ No Non-sanitary waste scharged to the Title 5 system? ❑ Yes ❑ No Water meter rea ngs, if available: Last date of o upancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Ready Rooter Records: Pumped Oct. 2017 Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Site tube on truck Reason for pumping: Maintenance t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 170 Seapuit Road Property Address Peter Bentivegna Owner Owner's Name information is p required for every Osterville MA 02655 September 5 2019 page. Cityrrown 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: Septic tank installed Nov. 2017. D-box and SAS installed 11/15/2012. Certificates of.Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2'10"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: n/a feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 f c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 170 Seapuit Road Property Address Peter Bentivegna Owner Owner's Name information is required for every Osterville MA 02655 September 5, 2019 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 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: 10.5' x 5.5'x 5' 1500 gallons 4" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 5"at inlet, 2" at outlet 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? Dip tube and tape 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.): Inlet and outlet tees in place. Liquid level at outlet invert. Risers bring covers within 6"of grade. Recommend maintenance pumping every two years. t5insp.doc-rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 170 Seapuit Road Property Address Peter Bentivegna Owner Owner's Name information is required for every Osterville MA 02655 September 5, 2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (conQ 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 top of outlet tee or baffle Distance from bottom of cum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on purr ing recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as rel ed 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 ❑ meta ❑ 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 170 Seapuit Road Property Address Peter Bentivegna Owner Owner's Name information is Osterville MA 02655 Se tember 5 2019 required for every p 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 flo t 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.): One inlet, 5 outlets. Speed levelers in place. Slight corrosion in sidewall of H-20 d-box. Equal flow. No high water staining over outlet inverts. Riser brings cover within 6" of grade. t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 170 Seapuit Road Property Address Peter Bentivegna Owner Owner's Name information is Osterville MA 02655 September 5, 2019 required for every P page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump ch/ber, ondition of pumps and appurtenances, etc.): a 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: A ADS AR ADS ❑ leaching galleries number: ❑ leaching trenches number, length.- El leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 170 Seapuit Road V Vy Property Address Peter Bentivegna Owner Owner's Name information is p required for every Osterville MA 02655 September 5 2019 page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Inspection port shows 1"standing liquid at time of inspection. Light staining 2"above current liquid level. No sign of past hydraulic failure. 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 nflow . ❑ Yes ❑ No Comments(note condi n of soil, signs of,hydraulic failure, level of ponding, condition of vegetation, etc.): L Form:Subsurface Sewage Disposal System•Page 14 of 18 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection S g p y 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 170 Seapuit Road Property Address Peter Bentivegna Owner Owner's Name information is Osterville MA 02655 September 5, 2019 required for every P page. Cityfrown 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/ns ydraulic failure, level of ponding, condition of vegetation, etc.): III! t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sy stem•Page 15 of 18 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 170 Seapuit Road Property Address Peter Bentivegna Owner Owner's Name I information is Osterville required for every MA 02655 September 5, 2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately -\43 v S war t 1 I � f J o 5 t t 1 t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 170 Seapuit Road Property Address Peter Bentivegna Owner Owners Name information is p required for every Osterville MA 02655 September 5 2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope i ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >5 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: 10/10/2012 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: f I ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: maps.massg is.state.ma.us/oliver.ph p You must describe how you established the high ground water elevation: Test hole for system installation in 2012 found no ground water at 120" (elv=6.7). Base of SAS at elv= 12.4 per engineered plans. I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.712 612 01 8 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 170 Seapuit Road Property Address Peter Bentivegna Owner Owner's Name information is Osterville MA 02655 September 5 2019 required for every P page. CityrTown 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 � I t5insp.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 oq6 Commonwealth of Massachusetts Title 5 Official Inspection Form co _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments hew+ M 170 Seapuit Road Property Address kua Peter_BentiveAna Owner Owner's Name ---- -------1---- — -- — _ information is required for every Osterville_ �. _ MA _ 02655 November 10, 2017 CA 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 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Patrick T Sullivan use the return — -- - — --- ---- _- key. Name of Inspector. Ready Rooter.,ExcavtinQ Company Name PO Box 89 Company Address: -----'-- --- — Forestdale ---- __. .---------- -MA -- -=--- - 02644 City/Town State Zip Code 508-888-6055 _ _ _ _ SI12843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that th—e information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000.). The system: ® Passes. ❑ Conditionally Passes . ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Novembef 14, 2018 Inspectors Signature , Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or.greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 1 iI`C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 Seapuit Road Property Address Peter Bentivegna' Owner Owner's Name — required fo is Osterville MA 02655 November 10, 2017 required for every — _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have riot 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 co pletion of the replacement or repair, as approved by she Board of Health: will pass. Check the box for"ves", "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 j ie tank is less.than 20 years old is.available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 - Title S Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 1? Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 Sea uit Road .Property Address - --- — Peter Bentivegna _ Owner Owner's Name information is Osterville MA 02655, November 10. 2017 required for every -- _ page. City/Town State. Zip Code Date of Inspection B. Certification (cont.) -- ❑ Pump Chamber pumps/alarms not:operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cant.): ❑ 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 'broken, settled or uneven distribution box. System will pass inspection if(with approval of Board a of Health): ❑ broken pipes) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed / ❑ Y ❑ N ❑ ND (Explain below): f; - ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): -- -- -- ---- ------� .—.._._= ---- ----------- � it ❑ 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): j I 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.doc•rev.6116 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 M 170 Seapuit Road property Address Peter Bentivecgna Owner Owner's Name information is _Osterville _MA 026.55 November 10, 2017 required for every _ page. City/Town 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 tgXa surface water supply. ❑ The system has a septic tank and'SAS arpd 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. l ❑ 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 we'(**. Method used to determine distance: i '* This system passes if the well water analysis, performed at a DEP certified laboratory..-for fecal coliform bacteria indicates abse�t 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. r 3. Other: -------------- i . 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 M,day flow t5ins.doc•rev.6116 1 itle 5 Official fnsne:tion 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 170 Seapuit Road Property Address Peter Bentive na Owner Owner's Name --- information is required for every Osterville MA 02655., November 10. 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 well. ❑ �I 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 ppmr 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. =or large systems; you must indicate either",yes" or"no" to each of the following, in addition to the questions in Section D. Yes No i ❑ ❑ the system i�`within 400 feet of a surface drinking water supply the systeyn is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the sy$rtem is located in a nitrogen sensitive area (Interim Wellhead Protection Area 1WPA) 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.doc•rev.6116 - Title 5 Official Insoection Forn 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 170 Seapuit Road Property Address ---------- ---- --- ___---- --- -- Peter Bentivegna Owner Owner's Name ---- ----- information is required for every Osterville MA 02655 November 10, 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 El M 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) M ❑ Was the facility or dwelling inspected for signs of sewage back up? M E] 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)) 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): 621 GPD t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 1 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 Seapuit Road Property Address Peter Bentivegna_ Owner Owner's Name information is required for every Ostervllle. _ _ MA _ 02655 November 10, 2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2016= 326 GPD 9 ( Y 9 (gP )) 2017=416 GPD Detail: Sump pump? ❑ Yes ® No Last-date of occupancy: Current 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 to present? ❑ Yes ❑ No Non-sanitary waste dj5 harged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: -- ------- t5ins.doc•rev.6/16 - 1itle 5 Official Inspection Form.Suhsurface Sewage Disposal System•Pace 7 of 17 r Commonwealth of Massachusetts Title 5 Official Ins ection Form Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments M 170 Sea uit Roa d Property Address -- Peter BentiveQna Owner ---- ----- - :;• __ _ Owner's Name information is Osterville _ MA 02655 November 10, 2017 required for every _ _ _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use. oats Other(describe below: General Information Pumping Records: Ready Rooter records: Pumped 10/20/2017 Source of information: —Was system pumped as part of the inspection? ❑ Yes M No If yes, volume pumped: gallons — How was quantity pumped determined? — -- - - Reason for pumping. - - Type of System: Septic tank, distribution box, soil absorption systern . ❑ 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): f5ins.doc•rev.6/16 -Tithe 5 Official lnspeciion Perm:Subsurface Sewage Disposal System•Page 8 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 170 Seapuit Road Property Address Peter Ben_tivegna Owner Owner's Name ----!---- --- - ---- -- information is required for every Osterville _ MA 02655 November 10. 2017 _ page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date instailed (if known):and source of information: Tank installed just prior to inspection to repalce leaking tank. D-box and SAs installed 11/15/2012. Certificate of Compliance on file at Health Dept Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4. 10" feet Material of construction: ❑cast iron ❑ 40 PVC ❑ other(explain -- -- N/A Distance from private water Supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage `etc. Septic Tank (locate on site plan'; Depth below grade: - — fees Material of construction: ® concrete ❑ metal -❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: ---- --- -- Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: _10'6" x 5'8" x 5'6" 1500 gallons 0 Sludge depth,: --- — — t5ins.doc•rev.6/16 - Title 5 Official Inspection Form:Subsurface sewage Disposal System•Pane 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection I=orm Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 170 Sea uit Road Property Address Peter BentiveQna --------_ - Owner Owner's;Name information is required for every Ostervilie MA 02655 .. November 10, 2017 --—---- —----- -------- — ---------- page. CityfTown —_ — _ State Zip Code _ Date of Inspection D. System Information (cont.) Septic Tank (cont.) - Distance from top of sludge to bottom of outlet tee or baffle -- J Scum thickness --__-- - 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? Dip tube and tape 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.): Inlet and outlet tees in place. Liquid level at.outlet invert. Risers bring covers within 6" of grade. Tank is new. -- - - — w ,. Grease Trap (locate on site plan)` Depth below grade: feet Material of construction: ❑ concrete [.� metal .❑ fiberglass ❑ polyethylene ❑ other(explain): r' Dimensions: Scum thickness -- -- f- Distance from top of scuyh to too of outlet tee or baffle - Distance from bottom/of scum to bottom of outlet tee or.baffie . ----- Date of last pumping: Date t5ins.doc•rev.6116 - Title.5 Official Insoection Form:Subsurface Sewage Disposal System•Page 10 of 17 i Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Vol untary:Assessments 170 Seapuit Road Property Address Peter B_entivegna Owner Owner's Name information is required for every 0 terviale MA 02655 November 10, 2017 ----- = ——• -- ------ _-- ----._. - -- page. Rown y -- "< — ---State Zip Code Date of Inspection Clt 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 ofainspection) (locate on site plan;: Depth below grade: Material of construction: ❑ concrete ❑ metal / ❑ fiberglass El polyethylene ❑other(explain): �i Dimensions: — / Capacity. gauans ---- — — Design Flow: % gallons per day Alarm present: ❑ Yes_ . ❑ No Alarm level: i -- Alarm In,working order: ❑ Yes ❑ No Date of last pumping: pate Comments (condition of alarm and float switches, etc.. 'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Sins.doc•rev.6/16 Title S Official Inspection Form.Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts _ Title 5 Official Intpection Form Subsurface Sewage Disposal System.Form -'Not for Voluntary Assessments 170 Se puit Road Property Address Peter Bentive na --- Owner Owner's Name information is required for every Osterville MA 02655` November'10.'2017 page. City/Town State .Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site.plan): Depth of liquid level above outlet invert - Ct ---- Comments (note if box is level and distribution_ to outlets equalCany evidence'of solids carryover, any evidence.of leakage into or out of box, etc.): One inlet; five outlets. Speed levelers in place. Light solids carryover. No high water staining over outlet inverts. Riser brings cover within 6" of grade. _ Pump Chamber (locate on site plan): Pumps in working order: D Yes [] No* Alarms in.working order. ❑ Yes ❑. No* Comments(note condition of pump c mber, condition of pumps and appurtenances,'etc.): i "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, expiain why: . .x t5ins.doc•rev.6/16 Title 5 Offinal Inspection Form:Subsurface sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary.Assessments M_ 170 Sea uit Road i Property Address Peter Bentlye n�--__ Owner Owner's Name - ----_ information is required for every Osterville MA 02655, , November 10, 2017 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Type: ❑ leaching pits number -- 35-ADS leaching chambers number: ARC3616 ❑ leaching galleries number: leaching trenches number, length: El leaching fields number, dimensions: -- ❑ overflow cesspool number: — ❑ innovative/alternative systeft), Type/name of technology: -- Comments (note condition of soil,.signs of hydraulic failure, level.of ponding, damp soil, condition o> vegetation, etc.)-. Damp base with no standing liquid in inspection port at time of inspection. No sign of past hydraulic failure. s b pumped as `art of ins ection .locate on site Ian Cesspools (cesspool must e p p p p )( 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.doc-rev.6116 - Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments 170 Seapuit Road 'Property Address Peter Bentive nc� _ -- --- - Owner Owner's Name information is- required for every Cisterville _ _ MA 02655 _ November,10, 2017 page. Cityrrown State .: Zip Code Date of Inspection D. System Information (cone.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i Privy (locate on site plan)' Materials of construction: - --- ----- i Dimensions --- — - — Depth of solid --- - -- Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation. etc. r, :5ins.doc•rev-6116 - Title 5 Official Insoection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments 170 Seapuit Road Property Address Peter Bentivegna p Owner Owner's N,me information is required for every Osteryille _ MA-.--- 02655 November 10, 2017 page. Cityrrown — _ 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 C1 drawing attached separately J art 39 �) �i ------------- 10 5 `� l5ins.doc•rev.6/16 Title 5 Official Insoection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 170 Seapuit Road Property Address Peter Bentivegna Owner - — ------.-. --- ----- -- - ----_--- - Owner's Name information is required for every Osterville _ _ _ _ MA_ 02655 — November 10, 2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (coat.) —. -- -- ----�--` " Site Exam: ❑ Check Slope Surface water ❑ Check cellar El Shallow wells Estimated depth to high ground water: f —----- fee 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 2012 Date Observed site (abutting property/observation hole within 150 feet of SAS) I Checked with local Board of Health -explain., ❑ Checked with local excavators, installers- (attach documentation) ❑1 Accessed USGS database -explain: maps_massgis.state.ma.us/oliver.php `'ou must describe how you established the high ground water elevation: Test hole in 2012 to 120" (elv- 6.7) found no ground water. Base of SAS at.ely= 12.40 per engineered plies.----__ -- I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Fitle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System`Form - Not for Voluntary Assessments ` wM •'"c 170 Si-:apuit Road Property Address Peter Bentivegna Owner Owner N ime ----------- - information is required for every Csterviil, MA 02655 November.10, 2017 page. City/Town _ State _ Zip Gode 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 �J System InWmation — Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins.doc•rev.6116 Titlo 5Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION k`7® ��.� �� , SEWAGE# Q13k-) _ 3 VILLAGE ASSESSOR'S MAP&PARCEL 4Q a INSTALLER'S NAME&PHONE NO.t"� -C 50Y SEPTIC TANK CAPACITY tom✓ LEACHING FACILITY:(type) ��S �_ (size) t-e,cos<s Z NO.OF BEDROOMS �j C7 OWNER:S�—C'%=J' PERMIT DATE: \ COMPLIANCE DATE: l 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) Ile Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY 3 y C33- ` -Y r No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplitation for 33isposal 6pstrm ConstCUttion permit Application for a Permit to Construct( ) Repair(v�'Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. `'j O S �'�V Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. `7, - 3'Sr Designer's Name,Address,and Tel.N �r S �1 �.k L , -*) Fhb e.'sicA`-Q� vV�ti.4 6�6 G� Type of Building: Dwelling No.of Bedrooms Lot Size A<.1-47 'Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) '—� gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank k ScZ)p Type of S.A.S. Description of Soil 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 Certificate of Compliance has been issued by this Boa of Health. Si d Date /`7 Application Approved by Date Application Disapproved Date for the following reasons Permit No.-7�I��b7 Q Date Issued No. 2o Fee (Wi THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓� Yes PUBLIC HEALTH DIVISION, - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplicatlon for Disposal .6pstem Construction Permit Application for a Permit to Construct( ) Repair(Vj Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 1`Z O 5��.7v. 'C�cr b Owner's Name,Address,and Tel.No. Assessor's Map/Parcel q5 ( ® S _,A 3 US; rv',��,� OsA O S- Installer's Name,Address,and Tel.No. 2 Zu"Z Q=);-57 Designer's Name,Address,and Tel.No, Type of Building: Dwelling No.of Bedrooms Lot Size o? Ssq-R. Garbage Grinder( ) Other Type of Building No.of Persons Showers( -) Cafeteria( ) y Other Fixtures Design Flow(min.required) �" gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title ; Size of Septic Tank k S7__1_1)U Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) T ,` Date last inspected: Agreement: The undersigned agrees to ensure the construction and,maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. _ � I ed Date Si /7 / Application Approved by yI Date Application Disapproved b Date for the following reasons PermiiNo.zpa 3 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired((/� Upgraded( ) Abandoned( )by —D'C\ at �1 O �.e Lac J 4�' �c��c-� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated 1,b t IT I70/'1"` Installer "�N _,do , G: .a- G=��".LicJ� �; Designer #bedrooms 5 Approved design fl and The issuance of this permit s all not b�9construed as a guarantee that the system will fu ctio as esi n d. ' 1 Date I 9 2 Inspecltor— e --------- --- -- --- -•------ --------------- No. — 5 6 Fee l �0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal �ipstem Construction Permit Permission is hereby granted to Construct( ) Repair(✓� Upgrade,( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5`and the following local provisions or special conditions. Provided:Cons uctio must be completed within three years of the date of this permi Date 70 � Approved by TOWN OF BARNSTABLE LOCATION SEWAGE# a0 3s'; k VILLAGE ASSESSOR'S MAP&PARCEL e 'a- INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY s1nC) b'.e� LEACHING FACILITY.(type)Q2�5 1�k pLe 3,'(6 (size) 3 s'X c ol. NO.OF BEDROOMS tows OWNERS PERMIT DATE: (1 _ COMPLIANCE DATE:f((a 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) r Feet FURNISHED BYr �l �S 0 30-1 . 1 TOWN OF BARNSTABLE �.C:4"—0N CZO S a 1'l �A- SEWAGE # ,LLLAGE 05`terv1\ �Co) ASSESSOR'S MAP&LOT � arm INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Oy LEACHING FACIL=: (type) �� -`� (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility — Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I 1 I �,;��,,5.-�. Si�J�. �� 5�` .�� a n �j0� Q°�s NONo. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2[pphfation for Disposal 6pstrm Cons tCUCtion,Vermit Application for a Permit to Construct( ) Repair( ) Upgrade(„Abandon( ) ❑Complete System Vndividual Components Location Address or Lot No. tvovs4 Owner's Name,Address,and Tel.No. 33.5— Assessor's Map/Parcel \h� Sr ',C S�. Qs��ru�l�� 7 Installer's Name,Address,and Tel.No.50 Designer's Name,Address,and Tel No.S'O-IT—Q�--tR'-32SC) -0a3'3 Type of Building: Dwelling No.of Bedrooms J Lot Size 'IC,1d 5' sq.ft. Garbage Grinder( ) Other Type of Building <�kr_9. No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) -"5'0 gpd Design flow provided gpd Plan Date Number of sheets 1 Revision Date 11 1 Title Size of Septic Tank JpC7 n bN 6T ". .w�}Type of S.A.S. ��s �Q.G_�� Description of Soil S en-c. y , ' r 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 Certificate of Compliance has been issued by this Board of Health. ig O Date /® / Application Approved by II Date Application Disapproved y Date for the following reasons Permit No. Date Issued r No. y Fee y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for Bi8t1D8aY *pBteII1 Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(Abandon(.Y j[]Complete System E24n'dividual Components Location Addressor Lot No. 1 7O S�A�''; o ar Q Owner's Name,Address,and Tel.No.$fir'-Vow-Y335` Assessor's Map/Parcel Installer's Name,Address,and Tel.No.S'C)V-': 29-G©5'SJ Designer's Name,Address,and Tel.No.S10,1r- 3 Q s,::D G�,c�ad2.� �c�ci��•r CsrcGu�.�--:.,.� L.'.�,eA,A V�;viC�/C,5'A-1 L w��,v.•e�.t�`^.S G�7-c� � dys A a Q6cicl Type of Building: Dwelling No.of Bedrooms S Lot Size `'(C, ''TQD 5- sq.ft. Garbage Grinder( ) Other Type of Building r-_ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 7,5'd gpd Design flow provided oa gpd Plan Date A C .1 C��' Number of sheets Revision Date ) I Title Size of Septic Tank \ t;pc_� n<b%67-9',5-V,,N, Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ,� z�A t v;rye -`c3�xaakz� v Date last inspected: Z 'Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in w accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by.this Board of Health. ' ig 0 Date Application Appro ed'\by j�/ 0� ,!J1 ' - Date 1 ff pplicatiori Disapproved y a Date g; for the following reasons r 4� Permit No. Date Issued 9 01 THl E COMMONWEALTH OF MASSACHUSETTS � BARNSTABLE, MASSACHUSETTS Certificate of Compliance ..` THIS'IS`TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded Abandoned(1 )by ' - �.i ©c]�r;�' `�xG:a,c��'� nc at U � has been cons cted in ac rdanee ✓'° with the,provisions of Title 5 and the�for Disposal System Construction Permit No '� ct d Installe �e..n �L`�i�.a �' � .aLjg ',Nc ' Designer #bedrooms . . k's; Approved design flow gpd r The issuance of this permit shall not be construed as a guarantee that the system will function s de jgn•d. ,''`Date- s �% / 7 Inspector 5 J f------ - t---` - � - -f-------------------- ---------------- --------------------- -------------- ---- . . No. Fee-jM ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Bisposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair'( ) Upgrade( Vr Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio u beompAeted within three years of the date of this permit. Date Approved by / dry �, � ��rn; ��riru�P �� = AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOC,AT.'ON 1'70 S 1 i Vic 4 SEWAGE# VILLAGE—©S��rv\� ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. C.Vk(k\-to , 5-epA s eIL&� S 5 SEPTIC TANK CAPACIT-Y- �l S077 a-1R-�io LEACHING FA�rTY(:'(type)� P� `� (size) NO.OF BEDROOMS 1 BUILDER OR OWNER r 1_ eT`�✓3 ti ll e� o. PERMI'rDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by o ,fly o http://issgl2/intranet/propdata/prebuilt.aspx?mappar=095025&seq=1 11/7/2012 G } ''111J'Ily� A j � F A L' I to Y P - c � 0 a J { { / III .,Y &ad ®®ter ===yR Plumbing 4 Heating 4 Septic 4 Drain Cleaning 508-888-6055 Ready when you are. P.O.Box 371 Sandwich,RSA 02563 44 Fax:508-888-0242 Patrick Sullivan 1 ,� ots@readY OMECom t. :4 Y Town of Barnstable P#_ /' 3 755 j ' Departinent of Regulatory.Services i Public Health Division Date 200 Main Street,Hyannis MA 02601 Date Scheduled— Time Fee Pd. �© toil Suitability ,Assessment fog- Semva Disposal Performed-By: LS Iy E Witnessed By: Location LOCATION&GENERAL INFORMATION / Address Owner's Name &,Jj ,j f/G'y/t-r- b S Aaaress D 5 3� Assessor's Map/Parcel: Gt S- / ZS Engineer's Namc G( tv✓ k7 NEW CONSTRUCTION / ( REPAIR Telephone# 2 7'f -7 . Land Use: 0 f ff,/� Slopes(96) � "" � �on Surface Stones o 4 i Distances from: Open Water Body IN I t 1 ft Possible We Areal J A ft Drinking Water Well IV!o ft Drainage Way_ NIA R ft Property Line q ft Other ft SIB]UCH:(Street name,dimensions of lot,exact locations of test holes&Pere tests,locate wetlands in proximity to holes) I TP— I f' Parent material(geologic)h L 0-6 n I O_iwac� Depth to Bedrock Depth to Groundwater. Standing Water in Hole: 1 Y A. Weeping from Pit Rce Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: In. Depth to 5gll moUles: ht, Depth to weeping from side of obs.hole: in, Groundwater Adf ustment ft. Index Well# ReadingDatc: IndexWetll¢vol____�_-__ Adj.Wtor.,,,,_.,,,.-. Adj.G'nundwnter Level L PERCOLATION TEST Dille Thne Observation Hole# �+-'(st-Jf--_ Time at 9" ' Depth of Pero lO 11 Time at 6" Start Pre-soak Time @ 0- 00 Time(91'4') End Pre-soak T.oo RateMin./Inch -Zr^`•^ Site Suitability Assessment: Site Passed Sitq Fatted: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back---------- ***I£percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to begimiizig, Q:ISEPTICkPERCFORM.D OC DEEP-OBSERVATION HOLE LOG Role# Depth from Soil Horizon Soil Texture .Sdil Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,'Boulders. "al"I 1—1 11 i to �y.96(iravei) 2-�1-Zt� Nl LS Ir l 9- 3 3 31�-I2o C, M-C Se --ca . I012 �►ti DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon P Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. " ��--++ o Nis en, %Ora e V1nn1 Z3 ly • M l-S b � 3�3 3L - I Z.o C M-C Sand I p . a 61 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Cmalatency.%Grilyrij DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soll Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders. Consistencv. Grovel) y Flood Insurance Rate Map: / Above 500 year flood boundary No— Yes Within 500 year boundary No Yes Z• Within 100 year flood boundary No-1 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 haturally occurring pervious material? Certification I certify that on ov. off. (date)I have passed the soil evaluator examination approved by the ti Department of Environmental Protection and that the above analysis was performed by me consistent with . the required traini g,expertise and experience described in 10 CMR 15.017. Signature Datb to vd I a-- Q:\S.HPTICIPERCFORM.DOC Town of Barnstable Regulatory Services Thomas F.Geiler,Director MAM^� + Public Health Division 039.�. Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 . Office: 508-862-4644 Fax: 508-790-6304 Date: 3S6 Assessor's Ma /Parcel .• C'�V � Sewage Permit# a o� p Installer&Designer Certification Form Designer: CSN T22!�-)y%eex,n Installer: Address: Vo 3 a A ao 1 Address: 6 fews I-iA 016 S 1 On Vag-' epgS:Y�gwas issued a permit to install a (date) (ins taller) septic system at_ ° (h%��- I"2d1 , O51,6'r✓►i ke, based on a design drawn by, (address) CS N 9n g ►"e.e %Ag dated 10 loll I"L 4v. I I ) I,) I L (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation,of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Re „ s. Plan revision or certified as-built by designer to follow. Stripout (if requ* , `gas ed and the soils were found satisfactory. s�ey LINDA J. GN o PINip tfl ' /IL in (Installer's Signature) o 4 5 �GIS7�a�O�4' (Designer's Signature) (Affix Designer's tamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSITED UNTIL BOTH THIS FO I'VIAND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice fonns\designercertification form.doc n, y. 7F7— Fps THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH J45 L). - s ..............OF...........AW-,#J......_.. 1 ...._..... App iration for Dispuiia1 Works Tomitrurtinn Prrutit ( Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal ystem at: V-5, �+/ y�� L ation/-Addrre/ss or t o. UC d.J�.-I�.�Vfet''ly -._ L/..B�Y. ..._•_... ._ M._ .. y�. �i/ ...- �-----""" L ' VZ�{r�j Owner Address ...................�� ..... •6-----_ --_-----•-•---__•. .......................... ----•------•......••__.._......_..______... Installer Address �j Q Type of Building Size Lot_._.,9 .�0.9.Sq. feet Dwelling—No. of Bedrooms........ ................................Expansion Attic ( ) Garbage Grinder (V) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) WOther fixtures ------------------------- .................................................................................... W Design Flow....... .......................gallons per person per day. Total dal y flew............. .__._._____•----.galons.� 1:4 Septic Tank—Liquid capacity/ gallons Length/A.y-..4 .Width.,, '1r... Diameter................ Depth__'_'r__,AE. W Disposal Trench—No. .................... Width... Total Length gth _..._._ x p pp 1 ----- /......a'otal leaching area-------------------sq. ft. Seepage Pit No._.•_____________.... Diameter....19"'........ Depth below inlet..... ..'d._. Total leaching area233%Z-_sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed by---I� se f4 ,TZe _._ 1V.y_E.......................... Date____ ,Wa Test Pit No. 1.4.-.-----minutes per inch Depth of Test Pit...h..Z........ Depth to ground water------- Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------ . -----------------------------•- ......_...------......-•------•-•-•----------------------•---------••---- Description of Soil------ .--�� a U -- ----•-•-•--•----•-.... ............ -----------------------------"_-•--------------------------------------------------------- W Nature of Repairs or Alterations—Answer when applicable......... ._A ...................................................... -----•----••---------------•••-.._..._..••---•---•--••-•-••••-•-•••---•-•-•-•-----.._...---.......-•-•-•-•-•--•-•---•-•---••••--•-•-••-•-••••••----•••-•--•-•---•-•--••-.............-••------•-------- Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with the provisions of i T'IE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the b and igned ._.... L( 2-0-$ Date Application Approved BY ------- ----------•-•• .............................. >Jj .....---•••--•- Date' Application Disapproved for the.following reasons:................................................................................................................ ..--•--•.....--•----•••-•••---•--•---•-••-----•------••--•--•----•--•----•••---•-•-------...-••-•------••--•.............••••---••••------•••---••-•--------•-•••••-•••-••----•-----•-•-••-•......•-••-- Date PermitNo.. ... ...-- ........... Issued-...................................................... Date No .r_...`:-tW� Fis...................... THE COMMONWEALTH OF, MASSACHUSETTS BOARD OF HEALTH .............................. } App1tra tton for. Disposal,Iforks tt�u ti orn e�nti� Application is hereby.made for a Permit to Construct X) or Repair ( ) an Individual Sewage Disposal System at: .. L cation'-Address or Lot No. Owner Address J a .................. --------------- '- .. ------ �, � - ----- .... .._. ._..---- ------ -- Installer Address UType of,-Building . ' Size Lot.._92&,-7...... ..Sq. feet Dwelling No. of Bedrooms..._ -Ex ansic Attic Gr rrba e Grinder a Other—T ype of.Building ____._. _...,. ____:.No of persons __.._.._ .:__.___. Showers"( ) ,= Cafeteria ( ) d Other fixtures . ...... ........ ........ ... .................. Design Flow.......- -:,_____ ........gallons per person per dad. Total daily flow ... ° _.__...._&Ions. WSeptic Tank—Liquid capacity gallons Length©_'_ ___ Width_.t...._ Diameter_____ _________ Depth_ _.___ . x Disposal Trench—No..................... Width._r.......y'...... Total Length....................Total leaching area... ...___.sq. ft. Seepage Pit No---------------------- Diameter _ .-A. Depth below inlet....4...:........ Total leaching areal� -------sq. ft. Z Other Distribution,box ( ) -�£ Dosing tank (d ) d, ! t ��gl a Percolation Results Performed by.. S�t"� 't ___ e ��__________________________ Date._•- ___._.. Test Pit No. 14_2-_____minutes per inch Depth of Test Pit...LZ. Depth to ground water.---_ ° _.,:.:.. :' 44 Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water............... - •• -•--- -•----------------•••--•----•----------------•-•----- Description of Soil......G -�'®�} -• ---r ......----`" 'S' " ----- w ..... ....-------•--- -------- ................... -•••-- x -------------------------------------------------------------------------------------------------------•--------------------• •...................... Nature of Repairs or Alterations—Answer when applicable._.______! Pt��M--------------------- ------•-- ---------------------------------------------------•-------•------------•-----...--•--...--•--------------------------------------•---------.....----------------------------.--._..---------•--•---•---- Agreement: The. undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T i= is p `�of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board pf-health-- ........� = r -•-- •-• -.-.-------••••--- - / v� Date Application Approved By..........4 .................... = / - :. _ - ---•- t' Date Application Disapproved for the following reasons:.................................................................................i............................. ............................................................................................................................................... Date ' Permit No.. .......L ------------- Issued....................................................... s Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................-OF.... ....�.�� +�... ..•...•• . � (9rdifaratr aaf, Taautphatttrr THIS IS TO CERT FY, That the .Individuaal Sewa e.-Disposal System constructed (�/) or Repaired ( } by....................... ............ Q '`�nb_�. ....----------------•- -----------:.__....._...._...---------------- --.... Installer . 4� f has been installed in accordance with the provisions of TIT. . 5 of The State Sanitary Code srescribed in the application for Disposal Works Construction Permit No----- _._. `__* _C.n L!.... dated---._ . .. ... .......... , <f. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE®`AS A GUARANTEE THAT YHfE . SYSTEM WILL FUNCTION SATISFACTORY. DATE...................................::................••----------....------_.... Inspector..............--.................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r ........ ....I.. ........ . No. ?....... Btgpaas a - arks watt ri wtt rrutt �t , Permission is hereby granted--------- -��:.............- --'---`-=•---- - :.....................................................---...... < to Construct (wl or Re air ( ) an Individt Sewage Disposal System at No.....�_ .?°_+!�. _ _ '_._ e4 1t_!_._X�__....... f t rl,_d-:L. y,__t'`�_ ................................................ Street as shown on the application fof Disposal Works Construction ,Permit -Nos T_?�� S ) -•--- Dated-- `' 1 ` lY��f1�_.. ....................... / ! Board of Health DATE--_!- FORM 1255 HOBBS & WARREN=tNC., PUBLISHERS - TOP OF FOUNDATION 24"diameter concrete covers 05TE RV I LLE, EL=19.4 raised to wrthm C'of fimeh grade MA (or as noted) Inspection Port and cap with magnetic marking tape to wrthm 3,of grade 515tinV fL=17.5+ EL=16.8+ fL=15.0-16.7(max) SYSTEM DESIGN CALCULATIONS i X /I � ��/� 3 SEWAGE DESIGN FLOW REQUIRED:SBEDROOMDWELL/NG@ INSTALLER TO VERIFY THE LOCATION OF ALL \Geva��el� //0 GPD/BEDROOM=550 GPD REQUIRED UNDERGROUND AND OVERHEAD UTILITIES _z 15.4t 18" min Cover for PRIOR TO THE START OF ANY EXCAVATION CV SEWAGE 005IGN FLOW PROVIDED: THIRTYFIVE(35)AD5 UN1T5 IN BED g 5.0+ H-20 Loading = CONFIGURATION INFIVE(5)ROW50F5EVEN(7)UN175ffACH. ACTIVITIES AND RELOCATE AS NECESSARY = o ExiStin /3 7+ x (SEE NOTE #1 5) ta�y n --� Vt =((550/O.74)/(4.6 FT2/FT)/5.0 LFJ =31 A05 005 REQUIRED(35 PROVIDED) m S fxistm 14.2± _ '' �° LJ fxstOn+ 13 67 N 13.50 13.30 62/ GPO PROVIDED > 550 GPD REQUIRED ea fwstrng g C5 5 Uit Gas Baffle 12.40 5EPTIC TANK CAPACITY REQUIRED: 550 GPD X 200% _ l l00 GPD REQUIRED rr� 00 S S90 p Road 5EPTIC TANK CAPACITYPROVIDED: EXl5TING 1500 GALLON SEPTIC TANK O �� Ln Qo�d 7 7: .. . Longest 5,+ Run 2�0 bo' N / THIRTY FIVE(35)AD5 ARC36HC A GARBAGE 015P05AL 15 NOT PERMITTED WI TH TH15 DESIGN FLOW Existing } - 27 /2 LOCUS (36/6802)LEACH CHAMBERS IN BED 5.7'+ 00 In In a� EX15TlNG /500 GALLON DB-9 CONFIGURATION (1-1-20 Rated) SEPTIC TANK D-SOX LEACH CLAMBERS a� fL=6.7+Bottom of Test Hole \�0 �-D FLOW PROFILE S N SITE LO C U 5 NOT TO SCALE 998 F NOT TO SCALE TEST HOLE LOGS 1 .) Assessor's Map 95 Parcel 25 2.) Certificate #I G8805 3.) Land Court Plan 5725-40 Test Hole#I (EL= I G.7±) 4.) This property 15 in a Zone it of a Public Depth Layer Soil Class Soil Color Comments Water Supply I CERTIFY THAT I AM CURRENTLY APPROVED BY THE 5.) Flood Zone: X500 DEPARTMENT OF ENVIRONMENTAL PROTECTION PURSUANT TO L� '1 0"-24" Fill 310 CMR 15.017 TO CONDUCT SOIL EVALUATIONS AND THAT 24"-20" A Medium Loamy Sand I CYR 3/3 THE 501L ANALYSIS HAS BEEN PERFORMED BY ME CONSISTENT I S3 2G"-38" B Medium Sand I OYR 5/G WITH THE REQUIRED TRAINING, EXPERTISE, AND EXPERIENCE 38"-1 20" C I Medium-Coarse Sand I OYR G14 Perc @ GG" DESCRIBED IN 3 10 CMR 15.017. 1 FURTHER CERTIFY THAT THE RESULTS OF MY SOIL EVALUATION AS INDICATED ON THE ATTACHED SOIL EVALUATION FORM, ARE ACCURATE AND IN 3 . ACCORDANCE WITH 310 CMR 15.100 THROUGH 1 5.107 Test Hole#2 (EL= I G.7±) LEGEND Depth Layer Soil Class Soil Color Comments EXISTING SPOT GRADE 0"-1 1" Fill 24x5 PROPOSED SPOT GRADE I I"-23" A Medium Loamy Sand I OYR 3/3 EXISTING CONTOUR \`\ 23"-3G" B Medium Sand I CYR 5/G 24- PROPOSED CONTOUR Linda J. Pinto, Certified Soil Evaluator �3' 3G"-120" C I Medium-Coarse Sand I CYR G/4 w WATER SERVICE LINE o OVERHEAD UTILITY LINES DATE OF TESTING: 10110112 P E ELECTRIC LINES 501L EVALUATOR: LINDA J. PINTO, P.E., CSN ENGINEERING BOARD OF HEALTH AGENT: DON DESMARAIS, BARNSTABLE HEALTH DEPARTMENT G GAS SERVICE LINE PERCOLATION RATE: LE55 THAN 2 MIN/INCH IN "C" LAYER TOP OF BANK - r - �--��- LIMIT OF WORK NO GROUNDWATER ENCOUNTERED �-� EDGE OF CLEARING CONSTRUCTION NOTES 0 FENCE TEST HOLE LOCATION 5T SEPTIC TANK 1 .)ALL WORK SHALL CONFORM TO THE STATE ENVIRONMENTAL CODE,TITLE 5 (3 10 CMR DB DISTRIBUTION BOX 1 5.000): STANDARD REQUIREMENTS FOR THE SITING, CONSTRUCTION, INSPECTION, UPGRADE, AND EXPANSION OF ON-51TE SEWAGE TREATMENT AND DISPOSAL SYSTEMS AND SAS SOIL ABSORPTION SYSTEM Reserve RESERVED FOR FUTURE USE FOR THE TRANSPORT AND DISPOSAL OF SEPTAGE, AND THE LOCAL BOARD OF HEALTH `'O.> UTILITY POLE REGULATIONS. CATCH BASIN 2.) ANY SEPTIC 5Y5TEM COMPONENT INSTALLED IN A LOCATION WHERE THERE IS POTENTIAL Bdrm FOR VEHICLES OR HEAVY EQUIPMENT TO PASS OVER IT SHALL BE DESIGNED TO WITHSTAND rDth SURFACE, SYSTEM SHALL BE VENTED TO THE FIRE HYDRANT AN 20 LOADING. IF UNDER AN IMPERVIOUS S DRINKING WATER WELL ■ CONCRETE BOUND AT+ 5PHERE. J MINIMIZE UNEVEN SETTLING, ALL SYSTEM COMPONENTS SHALL BE INSTALLED ON A STABLE MECHANICALLY-COMPACTED BASE ON SIX INCHES OF CRUSHED STONE. Open 9.I 4.) COVERS OVER THE INLET AND OUTLET TEES OF THE SEPTIC TANK,THE DISTRIBUTION BOX, Hall AND THE SOIL ABSORPTION SYSTEM SHALL BE RAISED TO WITHIN G"OF FINAL GRADE. I . LEACHING FIELDS, TRENCHES, AND OTHER SOIL ABSORPTION SYSTEMS WITHOUT ACCESS 5tor. MANHOLES SHALL HAVE AT LEAST ONE(I) INSPECTION PORT CONSISTING OF PERFORATED Garage c ° 18.7 --- 4" PVC PIPE PLACED VERTICALLY TO THE BOTTOM OF THE 501L ABSORPTION SYSTEM WITH A BENCHMARK CAP, TIED WITH MAGNETIC MARKING TAPE, ACCESSIBLE TO WITHIN 3"OF FINAL GRADE. Et ° ° ° )8.8 Top Corner Concrete THIRTY FIVE(35)ADS ARC3GHC (3G I G5D2) Bdrm L 1 5.) PIPING SHALL CONSIST OF 4"SCHEDULE 40 PVC OR EQUIVALENT. PIPE SHALL BE LAID Bdrm Bdrm/Famdy O� ° EL=18.7 (Assumed Datum) LEACH CHAMBERS O BED CONFIGURATION WITH I l l c. °' FIVE(5) ROWS OF SEVEN (7) CHAMBERS ON A MINIMUM CONTINUOUS GRADE OF NOT LE55 THAN 2% FROM THE BUILDING TO THE ° 4 SEPTIC TANK, AND NOT LESS THAN I%OTHERWISE. Btn / �� °° .. ° °a 35' G.) DISTRIBUTION LINES FOR THE SOIL ABSORPTION SYSTEM SHALL BE 4"DIAMETER CO Existing 5 Bedroom Dwelling b.2 8 ' '� � I 5 5 S' S 5' 5' S' ' Top of Foundation EL=19.4± 4.° SCHEDULE 40 PVC (OR EQUIVALENT) LAID AT 0.005 FT/FT. UNLESS OTHERWISE NOTED. LINES Second Floor ° . 18• ° SHALL BE CAPPED AT END OR AS NOTED. ° - // 8"BirchEx/stnsg H-20 Rated 5ept1c Tank 7.) LINES FROM THE DISTRIBUTION BOX TO BE LEVEL FOR THE FIRST TWO (2) FEET BEFORE 4__ a ° to be Utilized(see Note PITCHING TO THE SOIL ABSORPTION SYSTEM. DISTRIBUTION BOX SHALL BE WATER TESTED \ � 17 TO ASSURE EVEN DISTRIBUTION. 0 /l 9 f d l� d? xx f� x a fxistm9/ tic f Comi'onent5 to 17.7 ) � Q � 6.)GROUT TO BE USED AT ALL POINTS WHERE PIPES ENTER OR LEAVE ALL CONCRETE 3 �; 'beAbandoned(See Note#22J O ) _ STRUCTURES IN ORDER TO PROVIDE A WATERTIGHT SEAL. eth earrn \f xx ^ °� Q J v a .° 14 9.) HEAVY EQUIPMENT SHALL NOT BE ALLOWED TO OPERATE OVER THE LIMITS Of THE SEWAGE DISPOSAL FIELD DURING THE COURSE OF CONSTRUCTION OF THE SYSTEM. 10.) IN ACCORDANCE WITH 3 10 CMR 15.22 1, ALL SYSTEM COMPONENTS SHALL BE m �� a`f z Ent "�, \ 3 �' Inspection Ports(See Note#4) MARKED WITH MAGNETIC MARKING TAPE. Family I \\ ai \ ry�� I 8"Tree 17 Parcel 12 1 1.)THERE ARE NO KNOWN WELLS WITHIN 100'OF THE PROPOSED SOIL ABSORPTION �� m \\ ay \ /G.3, Town Water PLAN VIEW n� \ 6 l O m/n Abandon e ( Pit to be Abandoned(See Note#22) �(H OF i(.tgss SYSTEM. Offi e m t SCALE: I " = 10' 'L, 4C' 12.) FROM THE DATE OF THE INSTALLATION OF THE SOIL ABSORPTION SYSTEM UNTIL LINDA J. ti0 RECEIPT OF THE CERTIFICATE OF COMPLIANCE, THE PERIMETER SHALL BE STAKED AND I FLAGGED TO PREVENT USE OF THE AREA THAT MAY CAUSE DAMAGE TO THE SYSTEM. �/U I PINTO m 5.7 ccn I N D UNLESS Kitchen ° �+ n 13.) THE DESIGNER WILL NOT BE RESPONSIBLE FOR THE SY5TEM AS DES G E Sitting Rvom K Bth Garage No. 46 OI4� CONSTRUCTED AS SHOWN ON PLAN. ANY CHANGES SHALL BE APPROVED IN WRITING BY THE 15 --- I '` bbb DESIGNER. m a . . �sso O� FG, 14.)THE BOARD OF HEALTH REQUIRES INSPECTION OF ALL CONSTRUCTION BY AN AGENT OF Dmmg s NAL THE BOARD OF HEALTH AND THE DESIGNER. THE DESIGNER SHALL CERTIFY IN WRITING THAT first Floor 4.7 / 5.0 ° °/ THE SEWAGE DISPOSAL SYSTEM WAS INSTALLED IN ACCORDANCE WITH THE TERMS OF THE I Woods PERMIT AND THE APPROVED PLANS. 48 HOURS ADVANCE NOTICE IS REQUESTED. _ m 14 15.) LOCATION OF UTILITIES IS APPROXIMATE AND CONTRACTOR SHALL BE RESPONSIBLE ' 14.7 3 FOR DETERMINING THE LOCATION OF ALL UNDERGROUND AND OVERHEAD UTILITIES PRIOR TO ;/ 3.4 COMMENCEMENT OF ANY WORK. THIS INCLUDES, BUT 15 NOT LIMITED TO, REQUESTS TO FLOOR PLAN Surveil Work bp. DIGSAFE,ANY PRIVATE UTILITY COMPANIES, AND THE LOCAL WATER DEPARTMENT. 7 nP A & M Land Services I G. CONTRACTOR SHALL VERIFY THAT ALL WASTELINES ARE CONNECTED BY WATER TESTING NOT TO SCALE 8 ) mF,-��: B18 Route 28, Suite 3 WITHIN THE DWELLING PRIOR TO INSTALLATION OF ANY SEPTIC COMPONENTS. I I a I� 5 Best Yarmouth, MA 02673 Pb. (508) 737-1777 Emeil.• enaaland®comcest.aet m 14.9 17.)CONTRACTOR SHALL VERIFY EXISTING INVERT ELEVATIONS PRIOR TO INSTALLATION OF a \ ANY SEPTIC SYSTEM COMPONENTS. 18.) INSTRUMENT SURVEY CONDUCTED FOR PROPOSED WORK ONLY. SITE PLAN SHALL NOT ° °eG) REVISION I I/1/1 2: Added H-20 Notation to Existing Septic Tank BE USED FOR STAKING, OR ANY OTHER PURPOSES. m O I 4.1151TE PLAN Prepared for: g ` 15 19.),THIS PLAN DOES NOT CERTIFY, GUARANTrE OR WARRANTY COMPLIANCE WITH DEEDED OR ZONING BYLAWS, SPECIFICALLY, BUT NOT LIMITED TO, SIDELINE SETBACKS AND BUILDING m n HEIGHT RESTRICTIONS. OWNER IS RESPONSIBLE FOR OBTAINING SUCH A DETERMINATION I 3' �° �. SCALE: I " = 20' Laurie A. Bentivegna FROM THE APPROPRIATE AUTHORITY. Area=9G,705 S.F.±LOT 94 m a , P.O. Box 73, Osterville, MA I 20.) IF SOILS DIFFER FROM THOSE SHOWN IN THE SOILS LOGS, DESIGN ENGINEER IS TO I 40° Proposed Sewage D15FO5ai System INSPECT THE SOILS PRIOR TO PROCEEDING WITH INSTALLATION. ,n 170 Seapult Rd., Osterville, MA 2 1.) EXISTING 1 500 GALLON SEPTIC TANK TO BE UTILIZED. PVC TEES TO BE INSTALLED ON INLET AND OUTLET PIPES IF NECESSARY, AND A GAS BAFFLE INSTALLED IN THE OUTLET TEE. Prepared by: 22.) EXISTING SEPTIC COMPONENTS TO BE LOCATED, PUMPED DRY, FILLED WITH CLEAN I g5.37 SAND AND ADANDONED IN PLACE. AREA TO BE COMPACTED TO MINIMIZE SETTLING. d 780,6'�Z° W �� Roa CSN �j a a e 1331 w de INSPECTION NOTE: 01% L ` VA Engineering a 8•77, PRIOR TO FINAL INSPECTION BY THE ENGINEER, SYSTEM NEEDS TO BE COMPLETE INCLUDING BUILDUP FOR COVERS. 20 40 60 P.O.Box2030 Phone: 508 299-3250 /00'00' Teaticket,AM 02536 Fax:(5 8)548-5478 SCALE I"=20' C:\C5N\RR-5eapuit\RR-5eapuit-5D5 Plan.dwg Date: 10102112 1 Scale: As Shown I By: LJP Check: MTA I Project No. C5N0275 � - . y T i 9 _ ,r avb y, `, s All, y_ I (-)/�'�APF s - /i /N/S�+/t Cl f,ll• y J r Y/S %111,r'i COBS/ TlJ1/�1 S -- ~ ^C0POS tC. 7 -OA/TDl.//ZS AP 4A -_ ocu5 ¢••PVC ('7yP.a 20 , ° G` "•— J h o � -5'_T, "ate y �' E/�C,�/. 1"17 F�.� /�.�� sS'1 /."510 4A44P^l � F'T j p l�.e� /1150 -' ..J • ;O S;/- v/L := D. 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