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Commonwealth of Massachusetts
�K Title 5 Official Inspection Form
l; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Seth Goodspeed Way i^.a
Property Address3
Ann German
Owner Owner's Name
information is Osterville Ma 02655 4-4-19
required for every
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.
Imng out forms
A. Inspector Information
filling out forms P
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
rS Company Address
Sandwich Ma 02563
City/Town State Zip Code
rmv (508)477-0653 S113747
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑■ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Brett Hickey 4-4-19
...Ozfe:fi19.0a 09 W:Sa:D LOYp
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 has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes.conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Seth Goodspeed Way
v�
Property Address
Ann German
Owner Owner's Name
information is Osterville Ma 02655 4-4-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
W 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:
The system was in working order at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
f
Z Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Seth Goodspeed Way
u
Property Address
Ann German
Owner Owner's Name
information is Osterville Ma 02655 4-4-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N (I ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Y
Commonwealth of Massachusetts a"
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Seth Goodspeed Way
Property Address
Ann German
Owner Owner's Name
information is Osterville Ma 02655 4-4-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:.
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
(I The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ O Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ a Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
{
c� Commonwealth of Massachusetts
Ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I f'
100 Seth Goodspeed Way
v�
Property Address
Ann German
Owner Owner's Name
information is Osterville Ma 02655 4-4-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ a Liquid depth in cesspool is less than 6"below invert or available volume is less
than day flow
❑ Q Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Q 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.
❑ Q Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ Q Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ID Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following; in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Seth Goodspeed Way
Property Address
Ann German
Owner Owner's Name
information is Osterville Ma 02655 4-4-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or."no"for each of the following for all inspections:
Yes No
0 ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ 0 Were any of the system components pumped out in the previous two weeks?
El ❑ Has the system received normal flows in the previous two week period?
❑ a 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)
❑ E] Was the facility or dwelling inspected for signs of sewage back up?
El ❑ Was the site inspected for signs of break out?
El ❑ Were all system components, excluding the SAS, located on site?
El ❑ 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?
❑ 0 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:
0 ❑ Existing information. For example, a plan at the Board of Health.
❑ O Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Ial Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
T 100 Seth Goodspeed Way
Property Address
Ann German
Owner Owner's Name
information is Osterville Ma 02655 4-4-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 3
Number of bedrooms(design): Number of bedrooms(actual):
440/GPD
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
Permitted for 3 bedrooms with a 4 bedroom design flow. (deed restricted to 3 bedrooms)
1
Number of current residents:
Does residence have a garbage grinder? ❑ Yes Q No
Does residence have a water treatment unit? ❑ Yes No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No
information in this report.)
Laundry system inspected? ❑ Yes FE] No
Seasonal use? ❑ Yes [E No
See below
Water meter readings, if available(last 2 years usage(gpd)):
Detail
2018- 67,000gallons 2017- 85,000gallons
Sump pump? ❑ Yes ❑■ No
current
Last date of occupancy: Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Seth Goodspeed Way
Property Address
Ann German
Owner Owner's Name
information is Osterville Ma 02655 44-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner- last pumped more than 2 years ago
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
" Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Seth Goodspeed Way
Property Address
Ann German
Owner Owner's Name
information is Osterville Ma 02655 4-4-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
El 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:
2006
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ cast iron ❑■ 40 PVC ❑ other(explain):
Town water
Distance from private water supply well or suction line: 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
c� Commonwealth of Massachusetts --�
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Seth Goodspeed Way
V�
Property Address
Ann German
Owner Owner's Name
information is Osterville Ma 02655 4-4-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1'
Depth below grade: 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
1
Dimensions: 000gallons
911
Sludge depth: r�
2791
Distance from top of sludge to bottom of outlet tee or baffle
411
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
1219
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped every two years for maintenance.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Seth Goodspeed Way
Property Address
Ann German
Owner Owner's Name
information is Osterville Ma 02655 4-4-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: NAfeet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
NA
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Seth Goodspeed Way
V
Property Address
Ann German
Owner Owner's Name
information is Osterville Ma 02655 4-4-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
0'r
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.):
The d-box was in working order at the time of inspection.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Seth Goodspeed Way
V
Property Address
Ann German
Owner Owner's Name
information is Osterville Ma 02655 4-4-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No` I
Alarms in working order: ❑ Yes ❑ No'
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
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:
❑ leaching galleries number:
(4)3050 infiltrators 34'x12.16'
0 leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts r
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Seth Goodspeed Way
Property Address
Ann German
Owner Owner's Name
information is Osterville Ma 02655 4-4-19
required for every
page. City/Town 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.):
The SAS was in working order.at the time of inspection. Infiltrators were 1/4 full when viewed.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
c Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Seth Goodspeed Way
v�
Property Address
Ann German
Owner Owners Name
information is Osterville Ma 02655 4-4-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
NA
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts '
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Seth Goodspeed Way
Property Address
Ann German
Owner Owner's Name
information is Osterville Ma 02655 4-4-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑■ hand-sketch in the area below
❑ drawing attached separately
'Assessing As-Built Cards
'T QWN OF BARNSTABLE W
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3ON,�J�GyJlIN09A4990MO Li/�� SEWAGE#�a�Wty"�✓,�"
LAE ASSESSOR'S//MAF&PARCEL T
STALL NA r#O:, 4LCC�/.sTr fU�9 tr' -Jv�F
SEPTIC TANK CAPACITY y/t 6 t 6f rrsl.a C
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NO.OF BEDROOMS �— t^� .toz+ort
OWNEAi _,
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{X3MPLIANCF DATE: �(
Sspa A001I Distance Between the:
Maximum A ltitsteil CrroundwaierTsblc to the T3attorn of Laaching;I eciliry FCC;
Private Water Supply.Well and Leaching Facility{If any volts exist
on site ot`within 200:feet of teaching fat iiiiy) L
.'liege of tNefland,and t;eacn+ng Facility{3fcuty wetlsmds.txist.
within 3,00 feet of ioachipg faeilityj. Peet
FURNISTIBD BY
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t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Seth Goodspeed Way
Property Address
Ann German
Owner Owner's Name
information is Osterville Ma 02655 4-4-19
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
s❑ Check Slope
o❑ Surface water
On Check cellar
❑■ Shallow wells
Estimated depth to high ground water: NoGW@126"
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: 10-16-06Date
❑ 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:
A plan on file at the local Board of Health was used to determine high groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
c Commonwealth of Massachusetts v
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
100 Seth Goodspeed Way
Property Address
Ann German
Owner Owner's Name
information is Osterville Ma 02655 4-4-19
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
❑� A. Inspector Information: Complete all fields in this section.
B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
❑■ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
McKean, Thomas
From: McKean, Thomas
Sent: Wednesday, June 12, 2013 1:46 PM
To: Dabkowski, Cindy
Subject: 100 Seth Goodspeed's Way, Osterville
received a septic questionnaire form regarding the above-referenced address and provide the following comments:
-This property is restricted to three bedrooms maximum as per the disposal works construction permit issued in 2006.
- The computer room appears to afford privacy and is therefore considered a bedroom under the DEP definition.
Please provide a revised floor plan showing no door to the"computer room"and a minimum four feet opening at the
doorway.
1
' V-
TOWN OF BARNSTABLE
�!CATION /On 5atf cog4 y=0 SEWAGE#'9006- 4/5-�
VILLAGE ASSESSOR'S MAP&PARCEL jagILOff
01STALLER NAME&PHONE NO. f3�/7ac all,
SEPTIC TANK CAPACITY 14000641
LEACHING FACILITY:(type)3-IC rj/�81- �Y� (size) 3y JL dtl�,�
NO. OF BEDROOMS 3 - Gf yepraa*i bed h
OWNER 6
PERMIT DATE: /0-oZ y-06 COMPLIANCE DATE:
Separation Distance Between the:
Maximum.Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
i} t E--3
641' -
_3- a3 LkL� QN
s� Ji- 37 3
� - �o
a
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
s
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,, MASSACHUSETTS
� l
2pplication for Digs onl *p5tem Co-a5truction Permit
Application for a Permit to Construct( )Repair( ✓Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. /OQ$eA Goo 0.5 p 49Y Owner's N e,Address and Tel.No.
iL1 xy GF'oe1fgN w
Assessor's Map/Parcel ck /00 ` ;76G0*Wcjw 1
I /o$q 04Tt�rhllc, 3 Yq
Installer's Name Address,and Tel.No. ..r Designer's Name,Ad ress and Tel.No.
Vrticet D•to�ca-ll;altf Ar"r% ney er `�8` a4a&
BRfrogo sT- �.o,tN 9qt
ftaq--trGil oassh
Type of Building: IV I
��
Dwelling No. of Bedrooms oL �g O sq.ft. Garbage Grinder(Dj/Q
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow Z/W•Sa gallons per day. Calculated daily flow gallons.
Plan Date /o-/6 06 Number of sheets / Revision Date
Title _
Size of Septic Tank ljoo666 eX.X ns: Type of S.A.S. i R rs - - a06'0—°(.r 3yxl,lti
Description of Soil At d r'd
Nature of Repairs or Alterations(Answer when applicable) �vMf trcMnve tCACtt Del , l l e.11 l{—�►�
yt 5
l� C�_ 3y X to •l6` leActt-� ic(p
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss d by this o d of He
Signe Date iXIT.93 0200
Application Approved by Date
Application Disapproved for the following rea67
Permit No. yAz2 Date Issued
No. ' Fee !lQ
''+ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ►�,
tre's
PUBLIC HEALTH DIVISION -TO%YN OF BARNSTABLES MASSACHUSETTS
Y 2ppfication .f_or Mi p nl *pgtem Co ttruction Permit z
Application for a Permit to Construct( )Repair(IlUpgrade( )Abandon( ) D Complete System ❑Individual Components
Location Address or Lot No./�_ .j�T/) G oo U.Sf P e �+��� Owner's re,Address and Tel.No.
/,vx/ GF2/`��aa/ r.�n
Assessor'sMap/Pazcel 'Pe � �! /� Se%hGoojSpre�
Installer's Name Address,and Tel No. .� Designer's Name,Address and Tel.No.
rv�e �tacall �st�� P��scn hlcyer 3Cd- �lGa3
Type of Building: (JN
Dwelling No.of Bedrooms3 Lot Size U'1 y sq.ft. Garbage Grinder( g
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow '/�U.S E5 s gallons per day. Calculated daily flow yyo gallons. ,
Plan Date %Q-i6-06 Number of sheets / Revision Date s'
Title A-
Size of Septic Tank (�QOO G,�I, N 1C 4, '�� Type of S.A.S:1 I + r r.'T.r s -.`/- i f i3 y x gj�3o$U v:+ +
Description of Soil LJjjj
Nature of Repairs or Alterations(Answer when applicable) w it1l1-Y f c r1\,uv e 1 eA c" 0, l I A � II �l q-
kcA
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance.with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health,
Signe ?,rZfGG«_ !,✓, /J DateOC.7. n o)QO 6
Application Approved by l Date
Application Disapproved for the follown eao _
�i
Permit No. Date Issued
—— e —— -------------------------
THE COMMONWEALTH OF MASSACHUSETTS
K D BARNSTABLE, MASSACHUSETTS
�( Certificate of Compliance
t' THIS IS TO CERTIFY, that the On-site Sewage Disposal System,Constructed( )Repaired(1,�Upgraded( )
Abandoned( )by c,hc,0 c n _ eta A7 C
at �p 50-6, - has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ia' �� ! dated
Installerlr�.c c hc� c_c._� L s 1 r r- Designer eaC t r I`(Ny e C
The issuance of this permit}�hal.j not be onstrued as a guarantee that the system�will`funEt7 n �s a igned.
Date Inspector r�'�---- --
Y.. -------------------------
No. s Fee
THE COMMONWEALTH OF MASSACHUSETTS
A PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
wigpo ar *pgtem Construction Permit
Permission is hereby granted to Construct( )Repair(V1 Upgrade( )Abandon( )
System located at 1oo
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: 'm
ust
n b completed within three years of the date of t Approved 's erml .
Date:_ �/� � �(
;1 PP b Y
o:•
f own of Barnstable Health Inspector
oFTHE toffy Regulatory Services Office Hours
q. 8:30—9:30
yP o� Thomas F.Geiler,Director 3:30—4:30
BARNMBLE• Public Health Division
9� MASS. g
1639. Aim Thomas McKean,Director
prED MA'I
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY.PR®G '1VIrAPPLICAN- *JSEPTIC'_,? VEST16N LIRE
Date:June 11,2013
1. General Information: Size of Property.75 acre
Address: 100 Seth Goodspeed's Way Osterville,MA 02655 Map 122 Parcel 089
Name:Ann E. German Phone#: 774-238-9211
2a.How many bedrooms exist at your property now?3
2b.Are you planning to add any bedrooms? no If yes,how many? 0
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?3
2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the
home and the proposed amnesty.apartment. Provide width measurements of any open doorways. Please label each room
clearly.
3. Is the dwelling connected to public sewer? NO
If the dwelling is connected to public sewer,skip questions#4 through#9 below.
4. Location of dwelling is INSIDE a Saltwater Estuary Protection Zone?
5 . Location of dwelling is INSIDE a Zone of Contribution to public supply wells?GP
6. Is the dwelling connected to an PUBLIC WATER?
7. Is a disposal works construction permit on file? YES or NO
8. If yes,how many bedrooms were approved according to this permit? Bedrooms.
9. Were any building permits obtained for construction of additional bedrooms? YES or NO
10. Is there an engineered septic system plan on file at the Health Division? YES or NO
11. Has the septic system been inspected by a DEP certified inspector within the last two.years? YES or NO
-------------------------------------------------------------------------------------------------------------------
FOR OFFICE USE ONLY Z 00 lJ
!
The Public Health Division has no objection to bedrooms a this r perty.
Special Conditions: mil vw, Wrbo&�_ �ea� t�s�n .N Pew, d,
Signed: Date: ?�
,ttt=
Town of Barnstable. P#
Department of Regulatory Services
Division Date
ubPhc Ae alth
cT
ruse.
200 Main Street,Hyannis MA 02601
-- Fee Pd.
�6
Date Scheduled ' ' Time
Soil Suitability Assessment for-
Performed ewage 17i osah
• y C�f' Witnessed I3y
'By: � —Is
LOCATION&GENERAL INFORMATION
Location Address,' 5 M -1►� l� s �}�/ Owner's Name A j�t N
1&-fEV l L LC— AA / Address [00 S� 1 t1
1 &
En neees Name bkxaen\
Assessor's Map/P4rcel:' �'c7.�/087 ,I
• I � q
NEW CONSTRU('110N REPAIR X Telephone# '6 a 36a`'.�6
•�D� {,
1lvb�
'Land Use Slopes(g'o) '•
�\ SurfaceStones _
i 7 2 �+e,,.—Drinking Water Well 2'�ft
7
Distances from: Open Water Body- S ft Possible Wee Area
� D U
prairiage'Way ft Property line
',:art
SKETCH:($treet name,dimensiods'of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes)
I
i
i
S I �d()
• ' . i 1
s .. ?4c
Parent material(gedlogic) l act C t O U+� S 1 Depth to Bedrock
>4
I W in from Pit FFACe..:... N �
Depth to Groundwater. Standing Water in Hole:' i ccP g
Estimated Seasonal'$gh Groundwater "
D TERMIN TION FOR SEASONAL HIGH WATrR TADLF. ;P.
M
Ads hod Used: _ I .�.
_i___ IS_d: _ + -� ��t0 gn11 H,9ttls: ' n. tf9
Depth db,�erved standing in obs.hole i°• Lci%
in, (iroundwuter Adjustment N p
Depth to weeping from side of obs.hole ,_ _ A laetor,..�.�-Adj.drautidwater l r;Vrl.
Index Wei!# _ Reading Date index Well 1061 -
/! 'PrueCO
4°.
PERCOLATION TES' D$it .1
FObservadon '1 I Time at
9�r /� A
Depth of Pere
,y " Time at b"
I z o Z ( Time(V-0)
Start Pre-soak Time.@ - .+
End Pre-soak L i 7-\`
L 2 Nt i
Rate MinAnch !
Site Suitability Assessment:. Site Passed Site Failed. Additional Testing Needed(Y/N) U
�:.
Original .Public He'�tth Division Observation Hole Data To Be Completed ottBack--
*'�*If percolafiibn testis to be conducted within 100' of wetland,,you m pct first notify the
Barnstable C4#servation Division at least one(1)wetYk prior to beginning-
DEEP OBSERVATION HOLE-.LOG Hole# _
Depth from Soil Horizon Soil Texture Soil Color Soil Other
.Surface(in.) (USDA) (Munsell) Mottling (Stnicture..Stones;Boulders.
Consii ent �%Gravel)
4-111
SA7Jto
�_ 11 Z LOAMU 10a N �as5cue
5'1-l20" G - 2 s`C
5h0 b
DEEP OBSERVATION HOLE,LOG Hole# '2-
Deoth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling. (Structure,Stones..Boulders..
Consistency,%Gravel)
It
Sib
A46-: t v Z.�i/ 713
AIIJ�
DEEP OBSERVATION HOLE-LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones.Boulders.
n ist
,t
Flood Insurance Rate May:
Above 500 year hood boundary No— r cs
Within 500 year boundary No` Yes
` Within 100 year flood boundary No 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? — e,5S
If not,what is the depth of naturally occurring pe iofv us material?
Certification i
I certify that on /6) qf (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protection and that the above analysis was performed by me consistent with
the required ' g,expertise and experience described in 3.10 CMR.15.011.
Signature Date/0 A0 O-=
Q:\.SEPTICtPERCFORM.DOC
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°' O0 DRAWING TYPE:
CONSTRUCTION-FIRST FLOOR PLAN J
E%9iINOST—T.- FIRST FLOOR PLAN.
/1
SHEET NUMBER
S—C—TO W CONSTRUCTED
03
g 0-27-2006 01.s 07P
1 NOTICE: The Town of Barnstable
. ant
seal gai advice to prepare a
grope worded deed
restriri n document
f
DEED: !RESTRICTION
WHEREAS, (n, OL, of
(owners name)�1%on i �)n t
iVIA
(addr$ss) l
, .
is the owner of I OD�- c �'1'� G� �Q,�,��, (��'�l sp 0S1 (1/LUZ;cated
at {� aV l I P VY)rx
MA(hereinafter referred to as i ..
and being shown pn a plan,entitled"Subdivision of land in
MA, Property of I'
i.
et al,
\� duly recorded:in Barnstable County Registry
°f 1
o� I,D+ 5
Deeds in Plan$ook J `Rage �
r i
1
Or on Land Court Plan Number i
WHEREAS, (�
lcir , was the owner of said lot has
(owner's name)
agreed with the Town of Barnstable Board of Healthao a restriction as.to the
number,of bedrooms which can be included in any home built on said lot as a.
pre-condition to obtaining.a disposal works'construction permit in compliance
with 310 CMR 15.000 State Environmental Code; Title V, Minimum
Requirements for the Subsurface Disposal of Sanitary Sewage
WHEREAS,the Town of Barnstable Board of Health, as-a pre-conditionto
granting a disposal works construction permit for a septic system in compliance
with 310 CMR 15.2.00,,State Environmental Code, Title V, Minimum
Requirements for the Subsurface'Disposal of Sanitary Sewage, and authorizing
the issuance of a building permitfor the construction of a single family home on
this property, is.:requiring that the agreement for the restriction on the-number of
bedrooms in any house constructed on the lot be put on record.4tb.t ie.
Barnstable County Registry of Deeds by recording this document, ,ore
'� ��►
deedr + '
1
F
1
L
T s_
Bk 21472 Pg 293 #67187
� t
NOW THEREFORE,N)n �C.t�zab(T-h es hereby place the
(owner's name)
following restriction on his above-referenced land in accordance with his
agmemenf.with the Th un..of ,whle# ietien- 44
run with the land and be binding upon all.successors in title:
1. 1 `'&CA o 7C'P (.�c S ��ria�-have.constructed
(address)
u�ppon the to a house containing no more thanbedrooms.
ih rt r\ Ly--2T r),).a erl agrees that this shall be permanent deed
(owners name) ;
restriction affecting located on I MA, and,
being shown on the plan recorded in Plan'Bdok , Paged
Or on Land Court Plan a i
� d
For title of see the following deed: Book , Page
Or Land Court Certificate of Title Number
Executedtas ed instrument _ 'day of Dorn C% 7
Owner's si a ure
E -
Owner's signature _
Owner's signature
i
i
COMMONWEALTH OF MASSACHUSETTS
022d% � s�
Then persoriqlly Epp®ace tie ahoy -tta
known to me to be the person who execrated the foregoing Instrument-and
acknowledged(}
the same to be free act and deed, before me,
i Notary
Pubt' t+
r ru r, MY co�nrniss,ibn ekplres:
i date
dead! r•• ...u.H°•!,,,°
BARNSTABLE REGISTRY OF DEEDS
,3 �-
EXISTING GTRUCTURE
eec. W
A ' enraaoom e
_ m
F e
[= G NNLN-M 0.05E, NNLK-M--T
a
O
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LL ui
$
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oorr.a,e�i �
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� p
DRAWING TYPE:
CONSTRUCTION-SECOND FLOOR PLAN
E%9LMO STRUOTURE
—.TURE TO RE CONSrRUOTEO O n SECOND FLOOR PLAN uarTan-,r SHEET NUMBER
na
04
TOWN OF BARNSTABLE
'CATION /O SEWAGE# ,Q006- yS-�
LLAGE Q ASSESSOR'S MAP&PARCEL I Ra,La F
1STALLERS NAME&PHONE NO. f .J�GLcc_IXT� sv8-1-1a,-y-ssaP
SEPTIC TANK CAPACITY-/,000 6,9/ 1_--xjs j,�}C
LEACHING FACILITY: �r/6 vet- 1y
.(tYpe1) n� ) (size)
NO. OF BEDROOMS 3 D.CiV-4�
OWNER Au&642/YI l
PERMIT DATE: /O-cRLI-06 COMPLIANCE DATE: l� 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) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
S { 0
.3-
S�
a
* i II
Town of Barnstable Health Inspector
F1ME r Regulatory Services Office Hours
g .: y _ 8:30—9:30
Thomas F.Geiler,Director 3:30-4:30
sARNsrABLE, * Public Health Division
MASS.
�A
t 1639. Aim Thomas McKean,Director
ED MAV
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM-APPLICANT = SEPTIC QUESTIONNAIRE
` Date:June 11,2013
1. General Information: Size of Property.75 acre
Address: 100 Seth Goodspeed's Way.Osterville,MA 02655 Map 122 Parcel 089
Name:Ann E.Gennan Phone#: 774-238-9211
2a.How many bedrooms exist at your property now?39
2b.Are you planning to add any bedrooms? no If yes,how many? 0
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?3
2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the
home and the proposed•arnnesty apartment. Provide width measurements of any open doorways..Plea*se label each room
clearly.
3. Is the dwelling connected to public sewer? NO
If the dwelling is connected to public sewer,skip questions#4 through#9 below.
n
4. Location of dwelling is INSIDE a Saltwater Estuary Protection Zone? .' O r
5 . Location of dwelling is INSIDE a Zone of Contribution to public supply wells?GP
6. Is the dwelling connected to an PUBLIC WATER? 433
7. Is a disposal works construction permit on file? YES o NO
8. If yes,how many bedrooms were approved according to this permit? Bed ooms. "n ,
i
9. Were any building permits obtained for construction of additional bedrooms? YES or NO
10. Is there an engineered septic system plan on file at the Health Division? YES or NO
11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
----------------------------------- ------- ------------------------------------------------------------------ �r
FOR OFFICE USE ONLY 2$J'^
nek
,p.�vCG�
The Public Health Division has no objection to_, bedrooms at this property. "� i
Special Conditions: +S
Signed: Date:
U ICES
43
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0. 9CATION SEWAGE PERMIT NO.
f LLACE
+�.i
INSTALLER'S NAME A ADDItESS
8 UIL0E R OR WNER -
DATE PERMIT ISSUED
OAT E COMPLIANCE ISSUED
C
LIS
1 oe7
t.-OCATION SEWAGE PERMIT NO.
;Z4jILLACE
05-r__ t+r i.,t-tj S e_
INSTA LLER'S NAME IR ADDRESS
l0-00
BUILDER OR YWNFR
DATE PERMIT ISSUED
� c�lJl
OAT E C0MPLIANCE ISSUED � 30
a
?y ! die
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 14" -�
Appliratiou for Diipnaal Workii T mitrurffvu Vamit
Application is�ereby de for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: 4," x,,pt ` _
Location A res or Lo
( 1011✓B'�...Address.-••--•....................................
1.4 Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling
—No. of Bedrooms......-...le................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ..................................
W Design Flow............2.24d...................gallons per person per day. Total daily flow...............2.'A.6..............gallons.
WSeptic Tank—Liquid capacity/00®.gallons Length................ Width-/®......... Diameter--------_....... Depth................
x Disposal Trench—No..................... Width.................... Total Length............ Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet..1 .............. Total leaching area-. l....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-' Percolation Test Results Performed by._W. ----- l�.��._._�`R.!"• Date......7.' .._"�.0'�.....
Test Pit No. 1................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........................
(x ----------------------------- . -----
Description of Soil -- ---.�. --�----•-••........ .--- f ------...... -..... /' ...........
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 iITL L 5 of the State Sanitary Code— e undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue y t oar 1 tlth.
e
d.. =---------- -=� .--..... .........--•----------------- --- r/p�,
r-AApplication Approved ---- ... ..� ---- ----�-- �-•-•--•...
Date
Application Disapproved r t e following ------------------------------------•-------------------...--------------------------------------------.......
-•-----•------•---........-•-------------•--------•----------...---...-----------........------------•------•----....--•----------•------------------------------------------------------•--------------
Date
PermitNo......................................................... Issued........................................................
Date
• No...................... FE$..........................
_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ----".........................OF.........................-----...........
Appliration for Binpuiial Works Tomitrurtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
............ - •-•••••----••-•---•--•-------------------------•----...........----•• .............................................-....................................................
ocahon A ess .,✓ � ,,,,.., a.► or
wn/ .y ,�y/-y/ -Address-
.�.. .....C`�Q + :....••-•-••....................•... .......---.. _ ....._... ........--------•--•------------.......
Installer Address
UType of Building Size Lot............................Sq. feet
..� Dwelling—"No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Buildin No. of persons............................ Showers
a YP g• -------------- P. ( ) — Cafeteria ( )
Otherfixtures -- --------------•----•---•......----•-......-• -----...•••-----••-------•-•-..__._........--------..----- ---•-----............•--•
w Design Flow............ ?2_�f'..... r _.___.gallons per person per day. Total daily,flow............... .............gallons.
WSeptic Tank—Liquid capacity./40O gallons Length................ Width./A....... Diameter................ Depth................
xDisposal Trench—No. ..............:..._' Nidth.................... Total Length........,•,_r---- Total leaching area....� +;,;v___sq. ft.
Seepage Pit No-------------------_ Diameter.................... Depth.:below'inlet.-.:................ Total leaching area............__...sq. ft.
Z Other Distribution box ( ) Dosin tank
'-' Percolation Test Results Performed by. _ ! * 1 � - "Date__. "'" ... -----
,.� Test Pit No. I................minutes per inch De' of Test Pit...................:''Depth to ground water................_____
(% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
--- ---------••-••-
O. Description of Soil l2 ^ X �1.4 t»...............•--'�..r. ---- /�t ------`-`�!�-/. ...
I
M _-_.......N t-�_Soil....
....-- ----- ------- --------------------------------- -------------------- -------- ----------------------------------------------
w
U Nature of Repairs or Alterations—Answer when applicable----------......................................................................................
4
..._....................................................................................................................................................................................................
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with `
the provisions of TITIE 5 of the State Sanitary Code— TV undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued issuedK th oar o I -aIt
ned .. ,
g ---- .....................-
..
q s e�
Application Approved BY.... ..... ..... .....................
.................................................. .............................._..
Date
Application Disapprove or t e following reasons-s.................
-----------------------------------------------------------------•--....---•-----------•-----------•----'---------......•-------•---....------------------------........................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF............. .............................................
Trtifiratr of Toutpliana
TH I T TIFY, That the I dividual Sewage Dis sal System constructed ( ) or Repaired ( )
._
-- - ...•....................................................................................
at------••---..... • --•--------- -----•---------------------------------16f
-..
has been installed in accordance with the provision' .. r o The State Sanitar C in theP2�® f Y ,.
application for Disposal Works Construction Permit No......................................... dated......... ._.___...............................
THE ISSU CE THIS CERTIFICATE SHALL NOT BE CONSTRUED A G ARANTEE THAT THE
SYSTEM Wl FU TION SATISFACTORY.
DATE....-•--•--•--•..Y ------••-----••••••-•---•-•-•----------•-•••--.. Inspector........... .... .... --
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................OF....... �
No......................... FEE........................
�t��r.�a� k� ��att�#�tuan rriYti�
Permission is . reby granted ;--- ----.- - •----------- -----y----------.--------------------------
.............
-.-............
......
to Constru Rya f vi S , _ sal S stem
atNo. •r -• •.................................... ---- �/-
Street
as shown on the application for Disposal Vl orks Cons ruction Permit o _... .. ..,Da�t/ed. . .......
............................. ....... ..................................
r
/ Board of Health
DATE........ ............./:�1 .r5
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS f,
3
1
P A PROFILE
- / PLAN , T Y /C L PRI.�
- - Nor . TO SCALE
- SCALE FL, t%L �2•v '
STD. L T, WGT C.I. MH COVER
T F R P '
4 C.l. P/PE 4 Bl /BE !PE T/6NT JOINTS
• CUTLET LEVEL
FLOW L INE 0 —
- - T, /RST JOIN
OWEL L ING 10„ /4" O O
7,32
r .
Q
C.I. TEE
4 02 C.I. TEE S•67
i
T STANDARD PRECAST T4 '_� ; F
CONCRETE GALLON �> `
SEPTIC TANK , .
B„
DISTRIBUTION BOX I=
TO BE INSTALLED ON
LEVEL, STABLE BASE.
t SEPTIC TANK
TO BE INSTALLED ON
LEVEL , STABLE BASE
rl7 '
<i.
sV
2 //B'r TO 1/2 y' WASHED PEASTONFL % -12
• LEACHING. PIT.
t oa r�''cap` t v 1j 00 '
ALL AROUND FREE OF IRONS FINES
BASE TO BE LEVEL
AND {JUST IN PLACE
x2.exi`e►2V L"'�aaAC1=t ' BRICK B MORTAR COURES
A.tE_EA. t 00•. :eXM ��Y2 3/4,'.TO !-I/2" WASHED CRUSHED
AS REOU/RED TO BRING STONE ALL AROUND "FREE OF
A tU t7A to p PR a4A COVER TO GRADE. 24"C./. MH COVER
„ 5T. IRONS, FINES AND DUST /N PLACE. '
Al a':.: GOWG; L. eA,Ga-1 t>SAhlti•1 / AND FRAME
J
4� _
i Z;, P1hT. ,N 4" *` LEACHING Pl T SECTION---
8 FLOW LINE
f"� GA�'t,taAlL, ',
` VIP TP INLET -- - -�-
I oGID 69 A L-. ,.'S C i� (3 G.' 1 A AJ K � 4•> ,_ ' __- T
S_ PIPE t. CONCRETE :., 0 BE 4000 PSI . 28 DAYS ,
tt. m o 2. REINFORCED WITH 6" x 6" NO.6, GA. W.W.M. ',. ."
ro �. O
3. 2' ANO 4' SECTIONS ARE AVAILABLE FOR .GREATER.;
DEPTH REQUIREMENTS. x..
I�r i�fZlclF, D OPENING WITH 4-//8" y 4. NUMBER OF PITS REQUIRED :x
OUTER DIAMETER A Z
L. EC. Z,o , NOTE EXCAVATE -TO ELEVATION 3 .OR LOWER ,AS'.
�7� o N 4I /-3/4 INS/DE DIAMETER -
3 REQUIRED TO REMOVE ALL LOAM AND CLAY` BENEATH
REPLACE EXCAVATED MA
TERIAL ,
s . � aT PIT. RE LA P A ER L WiTH Gi.EAN,
GRAVEL DESIGNED GRADE ,
GR E TO GNEO G
PIZ
41
41-0
a
MIN. ,
EFFECT/VE DIAMETER _
(NO T TO EXCEED 3d TIMES EFFECTIVE DEPTH)
- - - - - - - -
' . . ER TAB G!U C= u,Lt E D
5o x +; p U ;.♦ p v m T. 15 17 S0.X.r�
62
FA1Q
[�
501L AND PERC DATA GENERAL NOTES
PERC. RATE G 2 MIN. /IN , p- 170& NO HEAVY EQUIPMENT TO RUN OVER SYSTEM.
SEPTIC TANK DISTRIBUTION BOX LEACHING PITS TO BE STANDARD
TEST BY I-UG {ram- 14 eLP (1NtA, 1'llAI'�t1IGK 4 Ah�SG�,} '
+ -r- PRECAST REINFORCED CONCRETE UNITS.
WITNESSED BY: J a N ►.1 J IS.LQ tom`( Imo• tom' f-{ • � ALL SYSTEM COMPONENTS SHALL BE INSTALLED .-IN. ACCORDANCE
TO REVISED TITLE 5 ; OF THE STATE ENVIRONMENTAL CODE, i
TEST PIT GR.,EL' .: aF�'!� DATE: 7 f$3
MINIMUM REQUIREMENTS FOR THE SUBSUFACE DISPOSAL OF 1
TEST PIT NO.I TEST PIT NO. 2
SANITARY ,SEWAGE EFFECTIVE . I JULY 1977., "
0 EL`�4J" ANY CHANGES TO THIS PLAN MUST BE `APPROVED BY THE
BOARD OF HEALTH. '; r
�DIvM AT COMPLETION OF CONSTRUCTION , PRIOR TO BACKFILLING- THE
� A M it
.61 w BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION
j - PI ER LINES /4" % LESS 'INDICATED PITCH ALL SEW NES I FT. UN 'IN TEO
rr1-370 OTHERWISE.
i
1
w o 4 ��.I tea kU A T e{�
DESIGN DATA
BEDROOMS 2 DISPOSAL
f EST. TOTAL DAILY .EFF. aZO GALS. m
I
SEPTIC TANK I000
LEGEND SfDEWALL AREA 2, � GAGAL./SQ. FT.
BOTTOM AREA 1�O GAL./SQ. FT. SEWAGE' D15P0, L. .J / .J TE1
o xoc7 EXISTING GRADE
LEACHING REQUIRED . 13°�'`�,5 SQ.FT.
t2G ACTAL LEACHING AREA 25! 5Z SQ.FT. FOR
ZONE: n oo FINISHED. GRADE a
i
y uJ tl1 Vi!A� E �Z 0, 00 INVERT ELEVATION �� lss (� i rG
j. DOMESTIC WATER SOURCE 7 t_.-_ __.
} MA • L�T li� h eT tt 6(.mo o t7 S t>re�y'� LU&-r
{! PROPERTY LINE ,$� _ '�'
rC3 .3l /�� ri. u�R r . �•q+ t�:/�. t2 X-1 h ll !7 L F &A A.
PLAN REFERENCE: : � .7
t SCALE* AS INDICATED AT
MEAN HIGH WATER I ED DATE
• 4
� 3
QhhuxA9;P tcL- So•o IzoA P A-T �`07' 1 D a
BENCH MARK DATUM -�', -- MARSH Al WARWICK B ASSOCIATES
a. ;. . BOX 801 NORTH AL M F T OU H
Q . -
/apt/ NAZ.4�D MASSACHUSET TS 0�556
ors, •
'
,