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HomeMy WebLinkAbout0629 SEA VIEW AVENUE - Health 629� Sea View Avenue Osterville P A = 114 053002 i 1 , �I Commonwealth of Massachusetts 53 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r ; ,M 629 Sea View Ave :a Property Address MURPHY, JENNIFER R & EDMUND F Owner Owner's Name 6 information is required for every Osterville Ma 02655 6/5/18 page. City/Town State Zip Code Date of Inspection ; ' �§a } 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 Q�g/w filling out forms S/,# 130(eit0 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain Q Company Name 35 Content Ln Company Address Cotuit MA 02635 City/Town State Zip Code 508-364-9587 SI 13522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal,.ysystem at this address and that the information reported below is true, accurate and complete:as'ofthe time of the inspection. The inspection was performed based on my training and experience:�6*:tki proper function and maintenance of on site sewage disposal systems. I am a DEP approved`s.ystem inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: !FN ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving.Authority-,- 6/6/18 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use 4 at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M •''y 629 Sea View Ave Property Address MURPHY, JENNIFER R & EDMUND F Owner Owner's Name requir required is Osterville Ma 02655 6/5/18 required for every pace. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1500 gallon septic tank. As well as a concrete distribution box and H2O 4 flo's B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5'sns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 629 Sea View Ave Property Address MURPHY, JENNIFER R & EDMUND F Owner Owner's Name information is required for every Osterville Ma .02655 6/5/18 page. City/Town State Zip Code Date of Inspection B. Certification cont. ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed 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 FIND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: I ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachu setts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 629 Sea View Ave Property Address MURPHY, JENNIFER R & EDMUND F Owner Owner's Name information is required for every Osterville Ma 02655 6/5/18 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 to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has.a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5iis•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 629 Sea View Ave Property Address MURPHY, JENNIFER R & EDMUND F Owner Owner's Name information is required for every Osterville Ma 02655 6/5/18 page. Cityrrown 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. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 r Y > Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 629 Sea View Ave Property Address MURPHY, JENNIFER R & EDMUND F Owner Owner's Name information is required for every Osterville Ma 02655 6/5/18 page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, 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): 550 t5 ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 629 Sea View Ave Property Address MURPHY, JENNIFER R & EDMUND F Owner Owner's Name information is required for every Osterville Ma 02655 6/5/18 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ® Yes ❑ No 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑' Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title'5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 629 Sea View Ave Property Address MURPHY, JENNIFER R & EDMUND F Owner Owner's Name information is required for every Osterville Ma 02655 6/5/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped in 2016 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(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): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 c Commonwealth of Massachusetts - Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM 629 Sea View Ave Property Address MURPHY, JENNIFER R & EDMUND F Owner Owner's Name information is required for every Osterville Ma 02655 6/5/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 4/29/93 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 1feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: p t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 629 Sea View Ave Property Address MURPHY, JENNIFER R & EDMUND F Owner Owner's Name information is required for every Osterville Ma 02655 6/5/18 page. City/Town 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick How were dimensions determined? 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.): 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 629 Sea View Ave Property Address MURPHY, JENNIFER R & EDMUND F Owner Owner's Name information is required for every Osterville Ma 02655 6/5/18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 629 Sea View Ave Property Address MURPHY, JENNIFER R & EDMUND F Owner Owner's Name information is required for every Osterville Ma 02655 6/5/18 page. CityTTown 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 Level and at normal level Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5irs•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 629 Sea View Ave Property Address p Y MURPHY, JENNIFER R & EDMUND F Owner Owner's Name information is required for every Osterville Ma 02655 6/5/18 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 4 Flo's ❑ 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.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form . s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 629 Sea View Ave Property Address p Y MURPHY, JENNIFER R & EDMUND F Owner Owner's Name information is required for every Osterville Ma 02655 6/5/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5irs•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 6/6/2018 Assessing As-Built Cards TOWN OF BARN STABLE p LOCAA P I4__W At/� COT�j1'SEWAGE # / VILLAGE 04,*t7rLj t_ ASSESSOR'S.MAP & LOT�J�•J INSTALLER'S NAME & PHONE NO.h Tt>F.dy l K1 qt u f� SEPTIC TANK CAPACITY 1 L 04) G LEACHING FACILITY:(type)_r—�D W,6jFF4so Ylsize)y�c�( S NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER7`Ow W BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: Z.3 �__ VARIANCE GRANTED: Yes No ,t I/FTIo FT AE 7g'FT 3lN 5—Fr �v F_r FT O v 3 -p t r b G � as F7- l� r q q FT'a iv 3 131 .3 q Fr KI http://www.townofbarnstable.us/Assessing/H Mdisplay.asp?mappar=114053002&seq=1 1/2 f Commonwealth of Massachusetts H F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 629 Sea View Ave Property Address MURPHY, JENNIFER R & EDMUND F Owner Owner's Name information is required for every Osterville Ma 02655 6/5/18 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file M t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form _ o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 629 Sea View Ave Property Address MURPHY, JENNIFER R & EDMUND F Owner Owner's Name - requir required is Osterville Ma 02655 6/5/18 required for every 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 ® drawing attached separately t5ins-3/13 Title 5 Official Inspection 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 629 Sea View Ave Property Address MURPHY, JENNIFER R & EDMUND F Owner Owner's Name information is required for every Osterville Ma 02655 6/5/18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 11/21/91 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 G TOWN OF BARNSTABLE LOCATION 'Gys. SEWAGE #�5to VILLAGE OS-r-k V k�q ASSESSOR'S MAP&PARCEL I� J� "6S3- 2 IN:S �S NAME&PHONE NO.—P�riCk6il-anmil c-/d8r 1'17q SEPTIC TANK CAPACITY /50 LEACHING FACILITY:(type) IflowAkws (size) NO.OF BEDROOMS 6- OWNER -Sc-o-t`a L.T`D -vP`u g 1" PERMIT DATE: C DATE ��15 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 #629 € Rear of Hse. 4q 40 79 i y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 629 Seaview Avenue — Property Address Scotia LTD Trust Owner Owner's Name information is Osterville MA 02655 May 28,2008 required for — every page. City/Town State Zip Code Date of-Inspection V Inspection results must be'submitted on this form. Inspection forms may not be altered in any way. - Important When filling out A. General Information ' ' forms on the - computer,use 1.. Inspector:. only the tab key to move your 'Patrick M.-O'Connell • _ __ _ cursor-do not Name of Inspector' use the return r key. Septic Inspection Services Co. _ Company Name' f� 189 Cammett Road. Company Address Marstons Mills MA 02648 — City/Town State Zip Code 508-428-1779' SI 12855 Telephone Number License Number B.,Certificatioln certify th'atfhave personally inspected the-sewage,disposaly system at this address and that the information•reported below is true, accurate and complete as ofthe 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 " e.+ ❑ Needs Further Evaluation by the Local Approving Authority ' s May 28, 2008 _ In pector's Sign -.- Date t`- �� M_ The system inspector shall submit a copy of-this,inspection report to the Approving uthority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a sh red system or has a design flow of 10,000 gpd or greater,-the insp,ector,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 serf to the buyer,'if applicable, arid'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. 08-134 Scotia LTD Trust.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of.15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ' 629 Seaview Avenue Property Address Scotia LTD Trust Owner Owner's Name information is required for Osterville MA 02655 May 28, 2008 - every page. City/town State Zip Code Date of Inspection B. Certification (cont:) f 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 thatany of the failure criteria.described in•`310 CMR.15.303 or in 310 CZAR 15.304 exist. Any:failurf criteria not a-valuated are indicated below. Comments: Tank is not in need of pumping at this time, leaching system shows no evidence of saturation or surcharge. 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 motal:scptic tank will pass.inspection if it is structurally sound.: notileaking and if a Certificate of Compliance indicating that the tank is.less than 20 years old is available.'v ND Explain:. ❑ Observation of.sewage backup or breakout 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 08-134 Scotia LTD Trust.doc-08/06 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wti 629 Seaview Avenue Property Address t y Scotia LTD Trust Owner Owner's Name Information is Osterville required for MA 02655 May 28, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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: - a . 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 153Q3(1)(b)that the;system:is'notfunctioning in a manner which will protect public health, safety;and'the environment: ' El Cesspool or privy is within 50 feet of a surface-water ❑ Cesspool or privy is within`50 feet of a bordering vegetated wetland or a salt marsh 2. System will'fail unless the Board of Health (and Public Water Supplier;if any) determines that the system is functioning in a manner that protects the public health, safety and'environment: w T > - ❑' 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. 08-134 Scotia LTD Trusl.doc•08/06 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 . 4. ; Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 629 Seaview Avenue Property Address Scotia LTD Trust _ Owner Owner's Name information is required for Osterville MA 02655 May y 28, 2008 - every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) C) Further Evaluation,is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered'A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes",or"No" to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters El ® - due to an overloaded or clogged SAS or cesspool 0 ® 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. 08-134 Scotia LTD Trusl.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 I , Commonwealth of Massachusetts fo Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 629 Seaview Avenue Property Address Scotia LTD Trust Owner Owner's Name information is Osterville MA 02655 May 28, 2008 required for every page. Cityrrown' State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes• No ❑ 0 Any portiori of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion°of a cesspool or privy is within 50 feet of a-private water supply well. ❑ .® -Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving,a facility with a.design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 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. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either,"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection ❑ El 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 to 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.' 08-134 Scotia LTD Trusl.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 I _ Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 629 Seaview Avenue Property Address — Scotia LTD Trust Owner Owner's Name information is required for Osterville MA 02655 May 28, 2008 - every page. Cityrrown 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 inforrnation..was provided by the owner, occupant, or Board of Health ❑ ® y 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? o ®. 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 El 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?, ® ElWas the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and locution of the Sib ii"„bscrpbi h 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)] 08-134 Scotia LTD Trusl.doc•08/06 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 629 Seaview Avenue Property Address. Scotia LTD Trust _ Owner Owner's Name information is required for Osterville MA " 02655 May.28, 2008 - every page. Cityfrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms-(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 0 Does residence have a garbage grinder? - ❑ Yes ® No Is laundry on a separate sewage system?'[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes. ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available(last 2,years usage'(gpd)): Sump pump? ❑. Yes ® No Last date of occu any: Unknown p :Y Date Commercial/Industrial Flow Conditions: ` Type of:Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title,5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 08-134 Scotia LTD Trust.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 a. kl• Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 629 Seaview Avenue Property Address Scotia LTD Trust ' Owner Owner's Name information is Osterville MA 02655• . May 28, 2008 required for every page. Cityrrown State Zip Code Date of Inspection - r D. System Information (cont.) General Information Pumping Records: Source'of information: None Was system pumped as part of.the inspection? '❑ Yes ® No If yes, volume pumped: gallons How was quantity.pumped determined? Reason for pumping: Type of System: . ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if.any) ' Innovative/Alternative technology. Attach a copy of the current operation and El maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the7DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1993 Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-134 Scotia LTD Trust.doc-08/06 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 8 o1 15 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ' 629 Seaview Avenue Property Address, Scotia LTD Trust Owner Owner's Name information is Y ,Osterville - MA` 02655 May 28 2008 required for � _ every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont) Building Sewer(locate on site plan): Depth below grade: feet 4 Material of constructie El cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet , Comments (on condition of joints, venting, evidence of leakage, etc.): - Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ` ®concrete El metal El fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: y years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) A ❑ Yes ❑ No Dimensions: 10.5' long x 5.8'wide-1500 gal 3 2„ Sludge depth; 30 Distance from top of sludge to bottom of outlet tee or baffle. Scum thickness �. 2 V 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 12" . How were dimensions determined? Measured 08-134 Scotia LTD Trust.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 f Commonwealth, of Massachusetts Title 5 Official Inspection-Form' - Subsurface Sewage Disposal System Form.- Not for Voluntary.Assessments 629 Seaview Avenue ' Property Address Scotia LTD Trust - Owner Owner's Name information is Y ,Oster�ille MA 02655 May 28 2008 required for ' every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) _ Comments (on pumping-recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence_of leakage, etc.): Liquid level was found at bottom of outlet invert, tees intact and clear. Tank is not in need of pumping at this time: 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 recommenrdations, inlet antl outletaee or.baffle condition, structural integrity, liquid levels as related to outlet invert;evidence of leakage, etc.): •Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):- Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ,[] other(explain): 08-134 Scotia LTD Trust.doc•0&06 f Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official, Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 629 Seaview Avenue Property Address Scotia LTD Trust Owner Owner's Name information is Osterville MA 02655 May 28, 2008 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . ) Tight or Holding Tank(cont.) Dimensions: Capacity: — gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (cond(ition of alarm and float switches, etc.): *Attach copy of current pum ping,contract(required).is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan):.- Olt Depth,of liquid level above outlet invert 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.): No solids or high stains present, liquid level at bottom of all outlet pipes. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08-134 Scotia LTD Trust.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 629 Seaview Avenue , Property Address Scotia LTD Trust Owner Owner's Name information is Y ,Cisterville MA 02655 May 28 2008 required for - ' every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont:) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation,not required): If SAS not located, explain why: Type. ❑ leaching pits number: ® leaching chambers number: 4 Flowdifussors. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: - ❑ overflow cesspool number: El 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.): Probed stone& soils around SAS and found no evidence of saturation or surcharge. 08.134 Scotia LTD Trust.doc•08106 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 s , Commonwealth of Massachusetts Title 5' Official, Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t - 629 Seaview Avenue Property Address Scotia LTD Trust Owner Owner's Name a information is Osteryille MA 02655 May 28,.2008 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): Privy (locate on siteplan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, sigris.of hydraulic failure, level of.pond ing,-condition of vegetation, ,etc.): 08-134 Scotia LTD Trust.doc-08/06 Title 5 Official,Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection . Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 629 Seaview Avenue Property Address Scotia LTD Trust Owner Owner's Name o information is Osterville ;MA 02655 May 28, 2008. required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.), 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. 1#629 Rear of Hse., 4 2 i 40 79 r . . . . Commonwealth of-Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 629 Seaview Avenue g Property Address Scotia LTD Trust Owner Owner's Name information is Osterville MA 02655 May 28,2008 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.),` Site Exam: ® Check Slope r Surface-water. Z Check cellar ® Shallow wells Estimated depth to ground water. ` 'feet Please indicate all methods used to determine the high groundwater 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: Area of system is considerably higher than surface water on opposite side of road. 08-134 Scotia LTD Trust.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE_OFFICE OF ENVIRONMENTAL AY FAIRS c DEPARTMENT OF ENVIIt0N1VIENTAL PROTECTION A . a TITLE 5 OFFICIAL INSPECTION FORM=NOT TOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Mpp PARCEL . Property Address:. caC 1L�t� r� 1�P/1LCcQ, WT Owner's Name: Owner's Address: L 4, -s" . EREEIVED Pate of Inspection: ��y��o�d�,�.�f�P)c� ' Name of Inspector(please print) � t f �-s 2 7 2�02Company Name ,Mailing Address: BARNSTABLELd' � LTH DEPT. Telephone Number: 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.tooSS eti6n.15.340 of Title 5(310 CMR 15.00.0). The system: V Passes Conditionally Passes Needs.Further Evaluation by the Local.Approving.Authority ails Inspector's Signature: Date191 dam' The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a.shared system or has a design flow of 10,000 gpd or,greater,.the inspector and the system owner shall submit the report to the appropriate regional office of the , DEP.The original should be sent to the system owner and copies sent to the buyer,_if applicable,and the approving authority. Notes and Comments l?/i,� C�u� ��'�. Al"fe,'y'2'11 ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This ins pection,does not address how the system will.perform in the future under the same or different conditions of use. Title 5 Inspection Form. 6/15/2000 page 1 f l Page 2 of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEWINSPECTION:FORM PART A CERTIFICATION(continued) Property:Address:" - ,'L Owner: r Date of Ins.ection: 5� C 1 Inspection Summary: Cfi"eck A,B;C,D orl[ALWAYS complete all of Section D A. •S stemPasses «a .h:ha.w not found anyTinformation 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. XJ Comments: B. System Conditionally Passes: } One or more systern 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 t1�eBoard 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): brbken`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 1'1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPE FORM PART A CERTIFICATION(continued) Property Address: �PC . "A Owner: � -77 ,16t Date of Inspection: d,(& e C. Further Evaluation is.Req:uired 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(l)(b)that the system is not functioning hi.a inanner;which will protect`public health"safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is.wiihin 50 feet of a bordering vegetated wetland or asalt 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. 'r The system has,a septic tank and SAS and the SAS is withit a`Zone l 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 supplywell". 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. z x _ z 3. Other: 3 s Page 4 of l l r OFFICIA,L.INSPECTION<.FORM`-NOT.FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION-FORM % 1 PART A CERTIFICATION(continued) f Property Address: - � Owner; Date of In pection: Jk�iw �;�/l� Cd D. System T�ailure'Criteria applicable to'all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes NV .. ' Backup of sewage into facility or'system component due to'overloaded or clogged S'AS or cesspool IV Discharge or pond.ing 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 distribufion'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 'h day flow _ Required,pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times Bumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. _ Any portion of'a cesspool or privy is within 50 feet of a private water supply well. Any portion,of a'cesspool or privy is less than 100 feet-but,greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water'analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organ ic.compounds indicates that the well is free from pollution from th'atfacility'and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,provided thatno'other failure criteria are triggered.A'copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.30 ,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 gild to 15,000 gPd• You_must indicate either"yes"-or"no"to each of the following: (The following criteria apply to large-systems-in addition to the criteria above) yes no _ the system is within 400 feet of'a surface drinking water supply the system is within DO 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 public water supply well If you have answered.'.'yes".to any questibn'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 3.10 CMR 15:304..The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1.1 OFFICIAL INSPECTION FORM-NOT-FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:FORM _`PART B CHECKLIST Property Address: ,/U`L OwIler; n E Date of ins ectiou: Check if the following have been done.You must indicate"yes.'or"no"'a.s to each of the.following: Yes No Pumping.inform atior,:-was provided by.the owae.r, occupant,or.Board of T-lealth Were.any of the system components pumped out in the previous two weeks _ _j,,-.Has the system received normal flows in the previous two week period? _ _ Have large.volumes of water been introduced to-,the systein recently or as part of this inspection? Were as built plans of the system obtained acid 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? a 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? _V/_ Was.the facility owner(and occupants if different from owner)prov_ided 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 Existing information.For exatnple,a plan.at the Board of Health Determined in the field(if any of the failure criteria related to.Part C.is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)].° . JK 5 \ Page_6 of 1] OI'I'ICIAL INSPECTION I'ORiVI : NOT I'O R VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION`:FORM PART C SYSTEM INFORMATION Property Address: Owner; Date-of I spection: �- OW CONDITIONS RESIDENTIAL Number of bedrooms(design) : Number of bedrooms(actual): DESIGN flow based:on 310 C R 15.203 (for example: l l0 gpd x#of bedrooms): -Ni:imber of current residents:y Does residence have a gar.ba a grinder es. or nod�. Is laundry on.a separate sewage system (yes ornq� . jlif yes separate inspection required] Laundry system inspected es or n�/y Seasonal use: (Yes or no). Water meter readings, if av, able(lasf 2 years usage(gpd)): Sump pump(Yes or no): M. - Last date of occupancy- s�?��Q�/; ,� ) COMMERCIAL/INDUSTRIAIC� Type of establishment:. Design flow{based on 310 CMR,15.203): gpd ' Basis of design flow(§eats%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): G:.tNERAL INFORMATION Pumping Records _ p Source of information:. . &("X 3%Zij?saJ�L Was system pumped as part of the inspection (yes.or no): If.yes,:,voltime::pumped:. •.gallons-,I-Iow Nvas gtianlity pumped detennined? Reason'for pumping: TYP OF SYSTEM. se tic Tank distribution boa soil. a bso tion s s tem Single cesspool_ g . _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): .. proximate a e of all co . .onents�alnsta led (if]rno��m)an��rce of information: . Were sewage odors-detected when arriving.at the site(yes or no)_� ..Page 7 of 11 OFFICIAL INSPECTION FORM--NOT FO.R VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION1 FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: r Date of l spection: BUILDING SEWER(locate on site plan),,46?": Depth below grade: Materials of construction: cast iron 40 PVC other(explain): Distance from private water supply well or suction line:. Comments(on condition of joints, venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) r/ Depth below grader Material of construction: ncrete_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: 10•,5 1X& �e 5- Sludge depth: /0 Distance from.top of sludge to bottom of outlet tee or baffle:. �!6 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�: How were,dimensions determined: �IIs1,� Comments(on'putnping recommend do n , inlet and outlet tee or baffle condition,structural integrity, liquid levels s related to outlet invert,evidence of leakage,etc.): GREASE TRAP: g�i.(aocate on.site plan) ✓✓�N 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: E Distance from bottom of scum to bottom of outlet tee.or baffle: Date of fast pumping: V Continents(on pumping recommendations, inlet and outlet tee or baffle condition,'structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Page S of 71 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(,continued) Property Address: _. t �. UL " Owner: 772—evv 4: Date of In pection: &, - God- 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/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: ,. 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,): ), a PUMP CHAMBE�� ; (locate on site plan) Pumps in working order(yes or no):: Alarms.in working-order(yes,or no):. 'f Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 g OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2>. Owner: ^h1a401�°v1 Date of Inspection: cZe CJC� SOIL ABSORPTION SYSTEM (SAS): �locate.on site plan;excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: aching 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, dam_ p soil;condition of veQeta'tion, etc).. p CESSPOOL`',""-(cesspool must be pumped as part of ins'pection)(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 ofpondnig,condition-of vegetation,,etc.): PRIVY_ (locate on site plan) Materials of construction: y Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure,- level of ponding,.condition of vegetation, etc.): 9 . Page 10 of 1 l OFFICIAL INSPECTION FORM NOT FOk VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR. TC SYSTEM INFORMATION(continued) Property Address:. Owner: 4 Date of In Section:r 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. N' o �f r i 10 Page I I of,l l OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner T Date of In pectioil: ,--i f SITE EXAM Slope Surface water Clieck cellar. Shallow wells Estimated depth to ground water, a 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: . :]2'hecked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water,elevation: „ `^ t! war _ 11 *° Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: U S�c�UI'e� i_, of No. Owner: �/ Address: lll'Uli'l ��� doe �f:. Contractor:. �5 Address: Notes: STEP 1 Measure depth to water table to nearest 1/10 �. Date Z � ®. L ..................... ......... month/day/year STEP 2 Using Water-Level,Ran9e Zone and index Well Map lo'cat site and determine: I ,f O.Appropriate index well.........:....... .:..:.. Water-level range zone ................... :.........f 1 STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth.to water level for index well month/year STEP 4 Using Table of Water-level Adjustments Tor index well .(STEP r STEP 2A), curent depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water level adjustment ..................:................................................... STEP 5 Estimate depth to high water by subtracting the water level adjustment(STEP 4) from measured depth to water level at s.ite (STEP 1) ......................... ...... � � Figure 13.-Reproducible computation i0i m. 15: _ 4.Ili.4uuW:W.4c.uuuuiiWWltiNu4ueL:rl:u�:leuuLLuiaLLu4u.ulln'+Wiw4WturY '-u iu:::JW:uWfiiu[li'i�nlJLueri4..'io.a.rl:rWwa'wlYl.WuuuL:wuw,vJiWurr4tW+wu�.i.uu:.sutiul:iYYa iWe'u1Wul.ereluu�iwuu 'lu'umw.'W.w+uLti�uluuuriuJAYeuJ.u+.1ik.UCJrWwit[Y.JatrW.Y:wu�1:W WLw.:luuuLuu:..rJ vrWuvwWW,u':u::ti4w Diu:Wc,WJWiwNUYa�wlLuuvuusuuWUWiiWY:'.YluiYr4w Yu.�:4r4muiYudWJUUWu'.IswwW�II�AJ:wl wru�u::liJa iu]vL.:Y.iJl;iuuliuwuWv..u'riv'i'i:L u...Jliva:Wwlv:W�d �a Aeadd. TOWN OF BARNSTABLE F 4.t)T 0 / LOCATIO� l - `� E��l-?0 CLcJ .�1.�'� � SEWAGE # �,,��� VILLAGE ��T`�,r/�/ 4,L..z� ASSESSOR'S MAP & LOT I/- INSTALLER'S NAME PHONE NOAJ_� i1/I iY_1 to 'I SEPTIC TANK.CAPACITY / L oe)' G "kz -- LEACHING FACILITY:(type) R 0 L'U61,F"Fll fO NO. OF BEDROOMS •PRIVATE WELL OR PUBLIC.WA-TER7`®ua W BUILDER OR OWNER JyL, A1Jiq DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: `)7 Z 3 VARIANCE GRANTED: Yes No : r j FTk1,N A. E ?el 7' S i n/ 4 FT` 3 FT C 0 ! F ► Fay a a A 44 61 3 y rr77 �7 Ll ,�R 4p 1t * �t `� tc ?Aec&,�A 53 )0,0 E.) No.. . ............... Fps ......._............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 1�..............OF... ........................................... -XvViirafion fear Dhip.aiiaf Workii Tomitratrtion Prrutit J � pplication is hereby made for is Permit to Construct ( or Repair .( ) an Individual Sewage Disposal "' st at: PTV 1;7 n3 V ( I�L.(:.... oc lion-Address r Lot o. _ �E..........................................................(...--- s .. v. � `i - ---•---•-----•-- Owner --7' Address a Installer r Address UType of Building Size Lot_.1' ............. Dwelling—No. of Bedrooms___..____._` ____________________________Expansion Attic (�C➢ Garbage Grinder P4 Other—Type of Building __________________ %____ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ...................................................... Design Flow........... .........................gallons per person gr da Total daily flow.._....._tic) ......................... W Septic Tank—Liquid capacityl5�_..gallons Length_o _� sWidth Diameter------ Depth.5.a " x Disposal Trench—No......`............. Width.....I:4.......... Total Length......s?Q.._.... Total leaching area__49! _______sq. ft. Seepage Pit No--------------------- Diameter.................... Deh below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box �Gfl Dosing ank (RE) _ Percolation Test Results Performed by......_ X.TE_� _4�C--- (,X.G.................. Date.................... ,aa Test Pit No. ......minutes per inch Depth of Test Pit....M.......... Depth to ground water... Test Pit No. 2...4-Z....minutes per inch Depth of Test Pit------(P-........... Depth to ground water---3e.8----------- ------------------------------- -- --- --------------- O Description of Soil.. Z Lo, -- -• 5ot(� '3` `�(�3E Q' '7 3.5 r U . ©�_God!�5 --�--....C............ ----------------------------------------- --..................................................................................... Wx �j0- l &A1S u eot c- ----------------•--------------- - ---_---------- - . . - ------ Ar...... .---------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable..____.......................................................................................... ----------------------------•-------•------•---------------•-----------------------•--...._._...------------•----------------------•--•-•-•--------------------------------------..................... Agreement: The:undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the_provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has the board of health. Signed . .................. ..�. Application Approved By .... ... ..- .. .. . . .. ! `+ re - I -- - ---- ----- - - -- -------------------------- . . - Application Disapproved for the following reaso s ...................................`....... ---.......---...........................------. ....---------- --.---------------- ............ .......... ............................................. ....... ........ Dare Permit No. . ........................ Issued ---------��/--.---��-- -/------- - Dace ik ��� 4 tea. 00 No.. ........__ 1, FEs.l::........................ THE COMMONWEALTH OF MASSACHUSETTS R BOARD OF HEALTH .. ---......OF....e�`�st ....7.. 1R C,+✓ Appliration for Disposal Works Tons rur#inn umi# Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: 1 � \ -.--L,?tion-AdLres_5 or Lot No. - _ Owner Address W 1 J t c ,i-a _,, 7 �, v _'�'4' ,l r' Installer Address "QLot...—. * _.Type of Building t Size Lot..-'=---`-----------------i Dwelling—No. of Bedrooms............Al............................Expansion Attic ( 4 ` Garbage Grinder (1W) Other—Type of Building No. of persons............................ Showers — Cafeteria 0.1 Other fixtures ..._.._.____•............... W Design Flow................�.......................gallons per person,ppr day. Total daily flow_.._......._]................................gallons. WSeptic Tank—Liquid capacity l�:l)__gallons Length._'-., .. Width.._ :.< .__ Diameter............:... Depth•-:_-__ ,,. x Disposal Trench—No.-----1............. Width..... .......... Total Length------ ....... Total leaching area._�_';- _------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box (Y`„)5 Dosingmxank (N�9, Percolation Test Results Performed by......ti%...... I_'=-.... ...................:•...:.._.._._..._.... Date........................................ Test Pit No. L. '......minutes per inch Depth of Test Pit......... Depth to ground water.._ Test Pit No. 2--- ^....minutes per inch .Depth of Test Pit------!........... Depth to ground water._._-._6z............. ...... _... _ :"; - -......................................................... ---:" . - - .. ••---- -- -- 4- -4- t ' � Lt\vwi�_ j} --_ ` GK7 ODescription of Soil... -----•------------•------ ------- ---- 1 = --__ ••--•-_ ---- - .-. . . ... ..... . W UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued--by the board of health. Signed ....................� f�... f,...-.. ------.--e..----..........-- .... .. s�� jJ �jre Application Approved BY . �!� ts ` j �"�Application Disapproved for the following reaso .........................:'.....................------........---..............-----------------------------. . -- ------- ...... .............. ..........--- q . _ _ _ ..............Date................... Permit No. 11---c3 ............................ Issued ........... .... f)ve THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --- --- ------------------ C'Ie>rtifirate of C�ompliartu THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.. ..............................:.. ............................. . .'........__............-. ......... .--------.......--- ------------------------------------------------------------------------------ �. / nsralle� _at ' '....... '... ... .. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ................................................ dated ----------- --------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.... 1 / e�J�------------------------------------------- Inspector -... ....THE COMMONWEALTH OF MASSACHUSETTS �. BOARD OF HEALTH OF � `aaa�,R:�tF...1< C.... C� No. FE ..............00 .......... Disposal Works Taantrnrtion rrntit Permissionis hereby granted.............................................................................................................................................. to Construct ( ) r Repair ( ) an Individual Sewage Disposal System at No.•-••-•--•-•-•---•---`-�G''�-,,t-(f:_'� I �'N v '.:_=! �!t C.& 1 ' l t- -_... ...•-- •.....------• ........... a Street Cas shown on the application for Disposal Works Construction Permit No.. :_____ ated.___ ___ /. .... ............ ! 1 �� f Board of Health DATE.................:1............ J..---- -- --•----•-------•--. v FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS Page l of l .� , O'Connell, Timothy From: John O'Dea Uohn@sullivanengin.comJ Sent: Wednesday, December 08, 2010 5:05 PM To: O'Connell, Timothy Cc: 'Jennifer Murphy' Subject: 629 Sea View Avenue, Osterville Tim, As discussed, and required for the Building Permit Application signoff for a Kitchen and Bathroom addition offer the following for the file: Although the septic permit No 91-528 and the associated plan only reference the bottom area of the system as designed and installed,with the inclusion of sidewall the.system had more than enough capacity for 5 bedrooms .. per the code at the time. (12'x50'x1 gal/sf+ 2(12'+50')x2.5)) =410,gal Ions/day `. It should also be noted that the property has been assessed for 875'bedrooms dwelling,and that the property has been sold at least twice as a 5 bedroom dwelling with passing septic inspections forb'bedrooeach time. And that the property is not in an area which would otherwise restrict flow. v > We appreciate your working with us on the Building Permit application today, and your filing this email in the properties records so that there.is no question in,the future as to the number of bedrooms. John O'Dea Sullivan Engineering'Inc 7 Parker Road Osterville, MA 02655 508-428-3344 12/9/2010 ti ti 4­0 S3-- 00 2, �6Z01) APPLICATION FOR PERCOLATION TEST AND OBSERVATION PITS LOCATION_ NO. VILLAGE LL DATE APPLICA -f ► FEE ADDRESS, TELEPHONE NO. c7� :t (Non-refundabl ENGINEER t ,G TE,�,EPHONE N0. , DATE SCHEDULEDlet (Applicant's signature ASSfiSSOR'S�bi11P & OTNOo � ��1�-i' • • • • 9 • 00000000 �00000000a0a0: 000 • 9, 0004 Gar -F SOIL LOG SUB-DIVISION NAME DATE t i 1 S •9 S TIME 10 Am EXPANSION AREA: YES.,---NO _(3,4�c 2 1 Nti r t-G ENGINEER: TOWN WATER PRIVATE WELL BOARD OF HEAI EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: 6F `Zv t -n'T2- ,- Ax PERCOLATION RATE t� - TEST HOLE NO: O ELEVATION: 14.(- TEST HOLE NO: 2O ELEVATION: :1 1 i 2 G HoRi2oN - '7 " 1-3 " 0 r1 0�t 2c-+ 2 3 A. ,+oQ,-toy, 1"= ►4' 3 3,• 14. q a-ra 0.7-v DRY 4 4 7 _ quo L�5 C.� LP!�le'yL 32 9 M,S,-r(L �DA-I 9 li.1 (� 1✓? J,f�, 9 2otieE oP �CVYIA TOrJ 11 C2 mot '- t � s cF, e)10 �2' A,,-It0 s^. y) 12 12 13 w �:2 C i t 'o'`• . 13 14 14 15 15 16 16 _ SUITABLE FOR SUB-SURFACE SEWAGE: . LEACHING FIELD_✓ LEA IHC NG PITS LEACHING TREN:CHE§�_� UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: 'u-7 ,a NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED. .ON PERC TEST APPLICATION • ORIGINAL: COMPLETED IN ENTIRETY BY P E. AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT see- ...... >Y i ... .-...._. .............._ .. ............."__ i Y+ k U; ....................... IN i r ..................... .......... .............. . ............ ............ ..................................... ._... , ._. .... .._-....._�....._ -------- A ....... ...,..„ ..._........_ .........._........._........_. ................ 1 2 ........._.,..._._.............._........__. ... . , ....... f _. .............................._... .. ._....._..... _........_.......................... ........ ro. 1\i\..p..'a.nvtt? x>...;x..LU���.> .Y•'a .a...a::..a>. 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CABINETRY r C ,h•A L - F is f 7- W/R19 FIBERGLASS INSUL.,1/2'BLUE BOARD W/SKIM COAT PLASTER ON INTERIOR 10'ALUM.FLASHING A*ate' -=(� �• EXISTING 1•X 4•DECKING(MATCH EXISTING) �—R-36 FIBERGLASS INSULATION DECK JOISTS(2-X 10•@ 1 2.O.C.-MATCH EXISTING)GRADE p:- r �"—EXISTING FOUNDATION � EXISTING FOUNDATION 1 X 3 CEILING STRAPPING W/12 BOTTOM STAGGERED' ��:� � �' BLUEBOARD,SKIMCOAT OF PIASTER METAL HANGER M1%t•Sa��° : : G D'-• #5 REBAR 2) - ` S 8•CONC.FON.W/(2)-45 REBAR• evlston a e: ( 24.O.C. t-' TOP,BOTTOM .p.,- COMPACT GRAVEL ."`�.��., • (_..., j SILT FABRIC 4'0 PERIMETER DRAIN v 45 REBAR(2) p' p• r., 24•X 1 2-CONC.FTG.W/ - P- (2)-#5 REBAR roject No: w - _D ! tale: raven By. r ! 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' QJ °°/ / / !� FLOOD ZONE: 4 Zone A14 EL12 All EL11 B & C r, Community Panel No. #250001 0016 D 0 OP / July 2, 1992 `�. o LOCATION MAP: ,►, ..................... \ \ - / / / r \ _\ 1 a1 P Scale: 1 = 2000 t I • / / / x 'A Lawn ©a �`� \\ a ASSESSORS REF.: ( ` ' \ ` Map 114, Parcel 053-002 1 I. ! Top 3Ef MN 6 NGVD 29 I // x.�� d d s �/ X x r L\ d o \\ DIRECTIONS: >y x /x \ \� o `\ A From Hyannis - Take Route 28 into Ostervill e. At the 1 `•. / ' f y - / /// �� r� �GF.�F X / x ;••' \ \\� \\ a\ ,° lights by White Hen Pantry take a left onto Osterville- i �x Brick o a \ o\ West Barnstable Road and follow e a gg to the end. Take a pp �/�/ Patio © \\ � Qcn A� left onto lw straight throu Main Street. gh a stop sight n toa the rend. Road, p, x/ x � \\ , and follow 9 9 P ke a right onto P "/ J L •- 1 on the I ft #629. Sea View Avenue; roperty is l / x/ \ Ia t I i I I 1 j y 4S• / ♦ �/! / // /j o� p`L n� `tij X I Edge Of `\\� \\ AP(Proximate I / / / \ f %` 2 St w f � '' r g` Dwellin ,i /r FEMA Zone Lines Salt Marsh \\ High Tide Line \ / / 1 xl ,� �/ / \ as per FIRM 250001 0016 D r rev Jul 2, 1982 Lawn X Lawn {Q��I /4 /'•: / l � � ! � � • Ei / u• it /� �� i ' / 1 /• � •' Granite StairscV e "may ;c y,11 \ N I ,� lawn Ry 1 0 c V Zv Shower \ 1..........................i f ! 1 , `i• \ \� 1� Enclosure '`• \ � Lawn ...................... ..•... ........ ... . ..................... O o f ( ! r I S 4 #Qi Pool -. \ I \ ( \ Arc �t0 ❑ �, N s i Lo p VIA 'i!� 1! i ' N6��3.2� �� � co N/F S ss \ Andrea E Schulze 6' �Ji9' , � q o N D z SEP 0 ,9 RECT 1 LEGEND: NOTES: PREPARED FOR: PREPARED BY: TITLE: Site Plan Guy wire Edmund F. Murphy 111 Sullivan Engineering, Inc. CapeSury Proposed Improvements O Guy Pole 1.) The property line information shown was �r ��.�'� �I aybrOO�C ROQd Utility Pole compiled from available record information. Ostervil/e, MA 02655 Osterville MA 02655 /�PO Box 659 7 Parker Road �e t ® Tree flagged by others ®ever MA 02030 O 2.) The topographic information was obtained (508)428-3344 (508)428-3115 fax (508) 420-3994 (508) 420-3995 fax T■ Deciduous Tree from an on the ground survey performed on capesurvOcopecod.nef 629 Sea View Avenue or between 06/APRI10 & 08/APR/10. - Barnstable, (Osterville) Mass. F- 3.) The datum used is NGVD '29, a fixed mean 20 0 10 20 40 80 Draft: JOD Field: RRL/MML Coniferous Tree sea level datum. - - Review: PS Comp.: RRL _—_- DATE: June 16, G 2010 SCALE: 1 rr nOr Project: 30005 Project # C700.1 WEST BAY ry C q w Q DESIGN D_�-,_TA SINGLE FAMILY- 4 BEDROOMS N NO GARBAGE GRINDER DAILY FLOW = 110 X 4= 440 C.P.D. LOCUS 8�5 SEPTIC TANK = 440 X 150% =660 G.P.D. USE 1500 GAL. SEA �J i 0 FLOWDIFFUSOR - USE FD 4 X 8 - S USE 4 (4 X 8 ) CHAMBERS IN A 12' X 50' WASHED S FONE FIELD AS SHOWN FND. SYSTEM IS WITHIN 250' OF A RESOURCE AREA LOCUS MAP /� THEREFORE THE APPLICATION RATE EQUALS / 1 440 G.P.D./.75 = 587 S.F. OF BOTTOM AREA IS REQUIRED t 12' X 50' = 600 S.F. OF BOTTOM � REA IS PROVIDED. SCALE 1 25,000 � / j 1 la 1 PERCOLATION RA-IE: ASSESSORS / 1 .6 o t � / p5 1t 1 INCH IN 2 MINUTES Gr LESS. MAP 114 PARCEL 53 co ZONE ���/j j / C.B. t 1 RF-1 & A.P, (U \�F. QP j/ / FND. P 1 FLOOD ZONE All (EL. 11.0') J O p4// O 1 72 1 PANEL 16 OF 25 COMMUNITY PANEL NO, 250001 0016C 1.9� MAP REVISED AUG. 19,1985 O / / t 1 f Q 5 1 t lb 1 t i ° t 1 fo I\� t 1 5 TP ! T nT 21 /� J 1 U' j j o 43,561 S,F-, ,1 r 1.00 Ac. o '�. 25' 0 N � 20.23 �0� I ' PRECAST LEACHING CHAMBERS s FD 4XB -- S 6 O Zc `o QO \ \ o 6v pF _ FLOWDIFFUSOR 00, 4 4� WASHED STONE f / e DISTRIBUTION\ BOX �0 p0 / I I Dg_5 1 j / 1500 GAL. / / z SEPTIC TANK �- // z p J 1 p° I- I 3 Lu // I / \ o - FND. U J w 10.00 ¢ I 3. 11 4 \ ^�1 / \ TP / / 1 50'± I N 87'00'42 W 347 1 rn 11.4 CD L6 3/4 l 1 c 1 WELL FOR ti /1 AGRICULTURAL PURPOSES S(97 1 1 ONLY 72 9A� ti / BENCH MARK \ TOP OF C.B. 1 S 15.00' \ C.B. FND. TENNIS GDUR1 JOSEPH P. & DEVONIA M. KELLER CTF 105707 L.C.C. 6857-P 639 SEAVIEW AVE. cr 11.8 I OSTERVILLE, MASS. can 02655 cCoo I- cQ cn cn mi < O U V) :�E Q 11.8 000 � I wrn `t- Z #11 Ln Q U 31 .62' 2.0' } 6.0' 6.0' 2.0' r PLANT WITH ROSA RAGOSA PLAN OR OTHER SALT TOLERENT NATIVE PLANTS. 1"= 20' EXISTING GRADE , ' GRAPHIC SCALE 0 10 20 40 1 " BIT. CONCRETE TOP 1 2" BIT. CONCRETE BASE 1 ) f 2 2 --=-==---=--=-=-__ ==___ -==___-_______---- ELEVATIONS. ARE BASED ON M.L.W. = 0.0' N.G.V.D 6" LOAM & SEED BOTH SIDES 01 6" GRAVEL BASE ©� FROST FREE WATER ELECT.TEL. T.V. CrrTTnNT A - n SCALE 1 " = 4' ! GRAPHIC SCALE 0 2 4 S TEST HOLES 24"DIAM. MANHOLE & COVER P-781$ 18"DIAM. PRECAST CONC. RISER & COVER SET WITHIN 12" OF F.G. DATE: OCT. 10,1991 70 WITHIN 12' OF F.G. ONE REQUIRED OVER BOTH INLET & OUTLET SITE PLAN ❑F- LAND BOARD OF HEALTH: D. MIORANDI IN BAXTER & NYE: D. DAViES OWNERS OPTION- BRING RISER 70 F.G. WITH CAST IRON FRAME & COVER EtEv.= 16.0' NO F.G.= 15'f TOP OF (OSTERVILLE) FOUNDATION EL. 16.0 o INV. 13.0' STAB l......� MASS . F.G.= 14.5t 1500 CAL.& BARN r SEPTIC TANK SUBSOIL 4 INV. -2 PAP DIST, INV. 1 2.6' 12.8' PERC. EL 13.0 :_= FINE SAND INV. = 11.4 40 P•v.c- eox INV. = 12.0' FOIE LAYERS SGH�pUIE INV. ;' MIN. JOSEPH P. & DE'VONIA M. KELLER OF 2�vPEASTONE° ood°oo°°°° f 2 PEASTONE 5E7 D. E30X ON 6" DEEP COARSE ,,,°d„°°° FD 4 X 8-S r°°°°°°°°°°° CRUSHED STONE BASE. SCALE = AS NOTED DATE OCT. 17,1991 TO EL. 10.4 REV. NOV.4,1991 MEDIUM 3/4" TO 1 1/2" PROFILE REV. NOV.20,1991 SAND o WASHED STONE BAXTER & NYE INC, NO • 2 No SCALE REGISTERED LAND SURVEYORS 4.0' --- - 4.0' -- -- 4.0' o CIVIL I.*.-NGINEERS EL &0 LOAM & SUB SOIL 12.0 N 00 OSTERVILLE, MASS,EL. 4.0 -12 LK" NO WATER MEDIUM SAND OBSERVED WATER SQLLIVAN WATER EL 2.2 _3 8 EL. = 2.2 JfQa. 29733 � LOAM & SANDa tom,ST #88079A