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TOWN OF BARNSTABLE 0-
LOCATION �� X-)H 6000,TRM-a W Y SEWAGE # ,200q
VII LAGE 05TERVILLE ASSESSOR'S MAP & LOT 00
INSTALLER'S NAME&PHONE NO. &5/49M EXC414 T>d7J
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) G �/ � 5 ! �� (size) `7
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: 313 v A
Separation Distance Between the:'
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility.
Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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FEE
COMMONWEALTH OF MASSAC14USETTS Ec
Board of Health, ;&✓YL,S bT UX MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Q Abandon( ) O Complete System 44 Individual Components
Location I/ S@ $ S s !h1 Owner's Name
Map/Parcel# /+ll f�� ✓z'f f �� Address
Lot# Telephone#
Installer's Name �X - Uv� Designer's Name
l
Address �Q� 611K /Z&9 t9j•�g MA Address 1-7,
Telephone# 1S U�9 2�dCj. —q 3&0 -Telephone# "_may 7 _5''3 j
Type of Building AS c,4 �� 9 k, � �1/t't 114 Lot Size /!I +t sq.ft.
Dwelling-No.of Bedrooms 3 3 6--G(�'�.-,2)Q ro�wn-� Garbage grinder ( )
Other-Type of Building ��4 l No.of persons Showers ( ),Cafeteria ( )
Other Fixtures
Design Flow (min.required) d gpd Calculated design flow Design flow provided ---,iS 7 gpd
Plan: Date I(ol G Number of sheets Revision/ rZ- Date
Title /�2n�cl�� C 5,t S Jim -&Va f/USG r4 , j/5 o,A 4-6od j
Description of Soil(s) d /�} i 0�Z�G �v� .3 G •' /M'Sew i
Soil Evaluator Form No. Name of Soil Evaluator��-tl/�C � Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees t ' tall th cribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees'to not p e system in eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
FEE J(!
Board of Health, �G r,'t:S 4 MA.
APPL-16il"ION FOR"DISPOSAL SYSTEM CONSTRUCTIONPERMIT
Application for a Permit to Construct(`) Repair( ) Upgrade Abandon( ) - ❑Complete System %I Individual Components
Location l/Jr se Owner's Name
Map/Parcel# !n'1G �Z2 ✓e-e hG Address 5w-tf
Lot# ��f Telephone#
Installer's Name �x �G� Designer's Name /��� /
Address l,e, 64x /Z-8 9 j G(G /� Address /-Z, Uk5 3-- �iuSS {�6 j t-Otq
jL_Telephone# �S�/� ZU .Cl`3 Uo (J Z�� �� Telephone# 1 S-� 7 ._S 3/ MA
Type of Building St �'�' �"— c7�nay /s't -/ Lot Size—lei �� I sq.ft.
Dwelling-No.of Bedrooms 9J>JVr _ )0 .wv - Garbage grinder ( )
't . Other-Type of Building /1)4 V No.of persons Showers ( ),Cafeteria
Other Fixtures
Design•Flow,(min.required) gpd Calculated design flow. -330 Design flow provided --2;,S77 gpd
Plan: Date �3)1 6 G14- Number of sheets rZ— Revision Date
Title 1101U112(Jz... d _ C S./3 lfrh �l✓Ul0!('4042. &o ad f,4,"jS
Description of Soil(s) d —5 r A t' S I-I S���i li tt H. S L ,3 C -124 � G.' lq_5co d Stt✓✓`114 f 1W,9—
Soil Evaluator Form No. Name of Soil Evaluator��{//ti/C�it l K Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to,itistall the above-d- cribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrr to not to pL7c a system in eration until a Certificate of Compliance has been issued by the Board of Health.
Signed " Date
U i ._ r� S. 3✓ -o L/
Inspections _
No. d v 13.7 I T FEE JRQ
COMMONWEALTH OF MASSAC14USETS
Board of Health, 0e4fn Si�✓'K MA.
CERTIFICATE OF COMPLIANCE
Description of Work: O Individual Component(s) 0 Complete System,&
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ).,Upgraded ( ),Abandoned ( )
by:
at sp Goy f.
r
has been installed in accordance with the pr visi ns1/of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. UO�/`���, dated Approved Design Flow \ (gpd)
i
Installer f U
Designer: Inspector: o Date:
C7 — "
The issuance of this permit shall not be construed as a guarantee that the system will function as,designed. ,S
.'_ ,.-,..�k:..w.•--�.�.- _.- ._ ... -^.zt•--"'T .. r.__•.-fit...-._�.,3-,.-+T � �"': �:..--'= "�-'t+,.o.:.:. r �__.+ �„_.1�1•:x�n �v-�.�a..
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No. U O J FEE y —
�OMMONWFALT14 ®F MASSAC14US ETIS
Board of Health, i�S b Le , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Con truct( ) Repair( ) Upgrade( X Abandon( ) an individual sewage disposal system
at r/,5 SJ� as described in the application for
Disposal System Construction Permit No.eZOO J� dated �l
Provided: Construction shall be completed within ree years of the date o this p )mt. Aftocal conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date 3 6 d Board of Health �'
TOWN OF BARNSTABLE '�
LOCATION 600'PTPE Y SEWAGE #
VILLAGE C7 ���L ASSESSOR'S MAP &LOT " J b
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY f
LEACHING FACILITY: (type)
(size) ` 9�
NO,OF BEDROOMS
AN Y
BUMDER OR OWNER
PERMITDATE: 3 `2k
COMPLIANCE DATE: U q
Separation Distance Between the. Feet
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site or within 200 feet of leaching facility)
Vidge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
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LO-C AT ION S E W A G PERMIT NO.
VILLAGE
INSTALLER'S /jNAME & ADDRESS
, dd
B U I-L D E. R OR ,OWNER-.* .
DATE PERMLT ISSUED
DATE COMPLIANCE ASSUED,
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u
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HE T
Appliratiun -for 43iiiVooat nrknnitrnrtinn rrni t
Application is hereby'made for a Permit to Construct 7) __o`r�Repair ( } an Individual Sewage Disposal
Syst t: '
'=..... .... --- -4p
Locati -Address or Lot No.p +
4! �i VC_. iel Zf ........................... ...... .. ......... .._______..
W _ Own r - � `/`•�L'�ddressu� �
1 ` ' .` kbv
Installer Address
•-----------•
UType of Building Size Lot...../_ ---Sq. feet
Dwelling—No. of Bedrooms---------- ..............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building _ - No. of persons._-------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures --•------------ ---------------------- -
W Design Flow................. '1�2_.._..............gallons per person per day. Total daily flow._........_.I. 0-_-_--___-.-.._-_.-gallons.
WSeptic Tank—Liquid capacityM....-- a ons Length................ Width._---..------.- Diameter---------------- Depth._.._-_-_-------
x Disposal Trench—No................... W ........... -------- T ength....._..____....__.. T al 1 ding area....................sq. ft.
See a e Pit No.... ................ e -__p g 9 �'D e o'�'n o al ael3ing area-- ---.�Y'._sq. ft.
z Other Distribution box ( ) Dosing tank y'.11` 77•-
'� Percolation Test Results Performed by.................... ..................................................... Date-_-.------------------------------------
al 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._.-.-_._--._-_.-___.--.
R'+ � =➢ -------------------
O Description of Soil-----------i-._L�.....� ',/6 k �` `tom ..:..6 ...�..:'_ "__ °s' i .
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 Article .XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board qt health] ��� •..
Wit! f1
Signed
c� 1�" 5
D Ite
Application Approved BY--------- ---- -�'�1 � ------------------- ----
--�-�
Date
Application Disapproved for the following reasons:__________________________•-------------------------------------------------------------------------------------
Date
-----•-•-•-----------•--••--•-------•---------------•--.-••-------------------------------•--------------------.--•-•-----•-------•---------------------••-•--------------_--.-------
PermitNo......................................................... Issued........................................................
Date
lvm
(t1
No. J//Jj _ F>�a................."......... _
t THE COMMONWEALT OF MASSACHUSETTS
BOARD OF `'HEALTH,
r_
Nop" rati"n -for Biq aottl Eorhii Towitrurtion Vautit
is hereb 'made for a Permit to Construct .,`�or Repair an Individual Sewage Disposal, ?V
,,.Application Y ( ) P ( ) ,r a
System at
Location-Address a f or Lot No.
• p/ /
.._..l_-i_. Y '.+C.....•°.+t'.r � -tr.....r°" ..Ilk
f•.
-' v Owner ` Address
W ......................1 ..�.............. �i°.l..t.r1'.�ti f
Installer Ff` Address
d Type of Building ./ Size Lot...14c2��._ .F S,c{ feet
U Dwelling—No. of Bedrooms----------, ,�________________ _Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building _______.______..p-, yp g __._.-____ No. of persons____________________._..__ Showers ( ) — Cafeteria ( )
a' Other fixtures __-__-_f�. -''_.
------------------•------------------------- .............................................................
Design Flow................... 0 ................ per person per day. Total daily flow___________ _�� ........gallons.
9 Septic Tank—Liquid capacity s Length---------------- Width............ Diameter___-_-_----_-__ Depth-.-____-_-__-
xDisposal"Trench—No Widtli __•-------._ .__ T,otal'Length __ - Total leaching area---------------- ---sq. ft.
See a e Pit No �_�"` ` Dimete- _____ De
P g P �� ---•••• Tota141eaeliiug area__�_�_�''__sq. ft.
Z Other Distribution box ( ) v Dosing tank
aPercolation Test Results Performed by.......................................................................... Date____-__-_------------------------__---.
Test Pit No. L_______________minutes per inch Depth of Test Pit_.----------------_- Depth�.to ground water------------------------
1:14 Test Pit. No. 2----------------minutes per inch Dept h.of"Test Pit-rR________s -------Depthl To ground water__-_____________.
,t -- __ _ _ - x ----------------------------
D Description of Soil------ 6t.-cx yyc „« '��-p j '`_,r - �'_ '- !_ .
x /f >� C,I� 11 r r
U
t,
W _.r-- r
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in,
operation'until a Certificate of Compliance has been issued by the board of health
'� 9a
Signed , ----- . .._.--• --- •-------- -- ---- _-•- ----------- --------------------------------
Application Approved By---------- •-- '' �-w --- -�-"-`_/ t7--.....
Date
Application Disapproved for the following reasons:-------_____ _______ ________ _- ___ _____________________________________________________
- ,
y Date
PermitNo. ------•-•--................... Issued-----------------------------......................x=
Date
ThJE COMMONWEALTH OF MASSACHUSETTS �
BOARD .,OF 'HEALTH
,.�.._""_` , aJ• Vow` -
........... ............. r
f
-.-.-.
�rrtf tr�tr' f � ut �i�titr. -
THIS IS:"--TO CERTIFY, That•the Individual Sewage Disposal System constructed (-") ,or Repaired ( )
, ; ,.mot-�rrs�. /_ r'1j'..f-'fiq --- T
by---;•---•-
- ------------ ----------` --------- -------
,# J ej Installer
-•--• -••-- -- ----- -------- -------- --- --------------
has been nistal�ed in.accordance with the provisions.of _ XI of The,' tate Sanitary Code as describeddrin the
applicatio}r for Disposal Works Construction Permit No -" -1 � '' dated ..__ Y 7
Tilt ISSUANCE OF THIS CERTIFICATE SHALL, NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUKC` ION SATISFACTORY
DATE_ d�}.A: ,''. Ins ector - '�- '`
----•--- ••-- P
Y ram. THE COMMONWEALTH OF MASSACHUSETTS
BOARDS OF HEALTH a
.............7 SL�1 + -1._...O F........... ' .f.�+ 1a s% .+ t✓z i r - ---�^- 'r'
NO. FEE:_:• ......•...
ispogl ork,i %.111omithirtion ramit
Permiss>pn is hereby granted.__:...�}._� !__________________'`......-��'- ---
to Construct or Repair-(t.t) an Individual Sewage Disposal System }r
at No........... ' '/ .�`;,,^..�-s e' [i . :,r «- 11f.t-t.- " " x-�:jfi�i��"°
- - -
-----
r Street ke x
as shown do the application for Disposal Works Construction Pepm2t No Dated:__- l- `; ._�.______.__.
Board of Healt M
DATE--- •-•-••--- ........................................................
k�y
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERSCIF
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1,bT 6E USED TO LOT LlWiaS
Barnstable Assessing Search Results Page 1 of 2
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Home: Departments:Assessors Division: Property Assessment Search Results
115SS
Owner:
HAMBLY, MICHAEL S& Property sketch Legend
Map/Parcel/Parcel Extension IEF i
122 /086/
Mailing Address - -
HAMBLY, MICHAEL S&
TAMULEVICH,ALISA M 2 ,�
115 SETH GOODSPEEDS WAY 3
OSTERVILLE, MA.02655 "
2004 Assessed Values:
Appraised Value Assessed Value
Building Value: $ 123,800 $ 123,800
Extra Features: $2,600 $2,600
Outbuildings: $500 $500
Land Value: $ 141,500 $ 141,500 Interactive Property Map: ap requires Plug in:
;• �" fir;
Totals:$268,400 $268,400 I have visited the maps before
or
Show Me The Map �✓
April 2001 photos available
Sales History:
Owner: Sale Date Book/Page: Sale Price:
ANDERSON, GEORGE&JEAN 12/15/1986 5462/324 $ 143,500
RANDLE, RUTH W 12/15/1984 4364/051 $0
RANDLE, EDWIN A 2579/269 $0
HAMBLY, MICHAEL S& 10/30/2000 13328/113 $ 175,000
2004 Tax Information: Tax Rates: (per$1,000 of valuation)
Town Tax $ 1,774.12 Town Fire District Rates Other Rates
6.61 Barnstable 2.01 Land Bank 3%of Town Tax
C.O.M.M. FD Tax $295.24 C.O.M.M. 1.10
Cotuit 1.52
Land Bank Tax $53.22 Hyannis 2.03
West Barnstable 1.36
h wn rn m s t b 2/De s/Administrative ervices/Finance/Assessin /... 3/26/2004
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}Barnstable Assessing Search Results Page 2 of 2
Total: $2,122.58 Due to rounding differences these values may vary
Land and Building Information
Land Building
Lot Size(Acres) 0.44 Year Built 1977
Appraised Value $ 141,500 Living Area 1628
Assessed Value $ 141,500 Replacement Cost$ 142,319
Depreciation 13
Building Value 123,800
Construction Details
Style Ranch Interior Floors Carpet
Model Residential Interior Walls Drywall
Grade Average Heat Fuel Oil
Stories 1 Story Heat Type Hot Water
Exterior Walls ClapboardVertical Sidin AC Type None
Roof Structure Gable/Hip Bedrooms 2 Bedrooms
Roof Cover Asph/F GIs/Cmp Bathrooms 2 Bathrooms
Total Rooms 6 Rooms
Extra Building Features
Code Description Units/SQ ft Appraised Value Assessed Value
FPL1 Fireplace 1 $2,600 $2,600
SHED Shed 80 $500 $500
Property Sketch Legend
BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished)
BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished)
CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area(Unfinished)
FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished)
FCP Carport GRN Greenhouse UUA Unfinished Utility Attic
FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished)
FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck
FOP Open or Screened in Porch TQS Three Quarters Story(Finished)
http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeS ervices/Finance/Assessing/... 3/26/2004
04/01/2004 10:20 5084775313 ENGINEERING WORKS PAGE 01
Town of Barnstable,
Y .
Regulatory Services
Thomas F.Geiler,Director
Public wealth Division
,,,►
163% �
Thomas McKean,Director
ZOO 1VIaln Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Desi ner Certification Form
Date: J
Designer: fY'Y\.r Installer: �}0� "
Address Ctz s 5�` \ Address:
A-
o � o 9T
On q j� c of la A'--- as issued a permit to install a WM1�'
(date) (installer) I ZG4r 13Z
septic system at��Lh (�o crdt based on a design drawn by�� 3I /�
(address) nil 6
CNcS dated PA
( signer)
L/ I certify that the septic system referenced above was installed substantially according to
the design, which m.ay include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State & Local Regulations. Plan revision or
certified as-built by desigtaer to follow.
46
(Installer's Signature)
aw
!Ib►
X` C.
estgner's Signature) (Affix De p Hire)
PLEASE RETURN TO HA STABLE PUBLIC HEALTH DIV�N. CERTIFICATE
OF CO11�1'LIAN �'II,L NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARI: RECE VED BY THE BARN TABLE PUBLIC HEAL DIVISION.
RANI{YOU.
Q:HealtWseptic/Designer Certification Form
COMMONWEALTH OF, MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
FAILED INSPECTIONMAP
PARCEI.
EAT 5 ,
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 115 Seth Goodspeed Way
Osterville, MA 02655
Owner's Name: Mike Hambly
Owner's Address:
Date of Inspection: November 17, 2003 RECEIVED
Name of Inspector: (Please Print) James M. Ford - DEC 10 Z003
Company Name: James M. Ford
Mailing Address: P.O. Box 49 TOWN OF BARNSTABLE
Osterville,MA 02655-0049 HEALTH DEPT.
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection.-,The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs'Further Evaluation by the Local Approving Authority
✓ Fail
Inspector's Signature: Date: November 19, 2003
The system inspector shall subm t a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
f f
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 115 Seth Goodspeed Way
Osterville, AM
Owner: Mike Hambly
Date of Inspection: November 17, 2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments: ,
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
l
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed .
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 115 Seth Goodspeed Way
Osterville, MA
Owner: Mike Hambly
Date of Inspection: November 17, 2003
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a
surface water supply,or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.. A copy of the analysis must.be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 115 Seth Goodspeed Way
Osterville, AM
Owner: Mike Hambly
Date of Inspection: November 17, 2003
J
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than i/2 day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
✓ Any portion of the SAS,cesspool or privy is,below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
Yes (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within-200 feet of a tributary to a surface drinking water supply
the system is located,in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped
Zone 11 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
f "yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
i
Page 5 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 115 Seth Goodspeed Way
Osterville, MA
Owner: Mike Hambly
Date of Inspection: November 17, 2003
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS, located on site?
✓ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions;depth of liquid,depth of sludge and depth of scum ?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems? '
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ Existing information. For example, a plan at the Board of Health.
✓ Determined in the field.(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
f .
Page 6 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 115 Seth Goodspeed Way
Osterville, MA
Owner: Mike Hambly
Date of Inspection: November 17, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd-x#of bedrooms): 220
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION r,
Pumping Records
Source of information: Pumped in 2002-per owner
Was system pumped as part of the inspection (yes or noy: No
If yes, volume pumped: _gallons--How was quantity pumped determined?.
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, date installed(if known)and source of information:
Jun. 15177-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
I
Page 7 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 115 Seth Goodspeed Way
Osterville, MA
Owner: Mike Hambly !
Date of Inspection: November 17, 2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 2'
Material of construction: ✓ concrete _metal fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age,confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: --
Scum thickness: 4"
Distance from top of sum to top of outlet tee or baffle: --
Distance from bottom of scum to bottom of outlet tee or baffler --
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
The liquid level was above the inlet and outlet tees and up to the top of the tank. Liquid appeared to be backing up from the
leach pit.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
7
f
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 115 Seth Goodspeed Way
Osterville, AM
Owner: Mike Hambly
Date of Inspection: November 17,_2003
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):.
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: None (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.):
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
F
8
f
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 115 Seth Goodspeed Way
Osterville, MA
Owner: Mike Hambly
Date of Inspection: November 17, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
c
If SAS not located explain why:
Type
✓ leaching pits,number: 1 -6'x 6'(1000 gal.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
The leach pit was full. Liquid was up into the riser above the top of the pit. The leach pit appeared to be in hydraulic failure.
The cover was 16"below grade. The bottom to grade was 9.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of'solids layer:
Depth of scum'layer:
Dimensions of cesspool:
Materials ofconstruction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 115 Seth Goodspeed Way
Osterville,AM
Owner: Mike Hambly
Date of Inspection: November 17, 2003
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.
j
,A plc g
I
3 o aq
O 3
10
Pagel] of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 115 Seth Goodspeed Way
Osterville, AM
Owner: Mike Hambly
Date of Inspection: November 17, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20 +/- feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing
approximately 20'+/-to ground water at this site.
This report has been prepared and the system inspected and failed of the date of inspection. This report is
1 not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
Commonwealth of Massachusetts
Executive Office of Environmental Affairs t
Department of Environmental Protection.
One Winter Street, Boston MA 02108 (617)292-5500 -
TRUDY COXE
G Secretary
ARGEO PAUL CELLUCCI • DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART A
CERTIFICATION
Property Address: 115 Seth Goodspeed Way, Osterville, MA Name of Owner: George Anderson
Address of Owner:Same
Date of Inspection: January 1,-2000
Name of Inspector: (Please Print) Gordon E.Bumnus
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: Gordon E. Bumaus '
Mailing Address: 215 Ost.-W. Barnstable Rd., Osteryille, MA 026S5 Map: 122
Telephone Number: (S08)428-5640 Parcel: 086
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
✓ Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails ;
Inspector's Signature: - Date: January 5, 2000
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS s
• ��a 7 2000 QV
t
TOWNO�FTHliOEFT� �®
05
revised ,9/2/98 Page IofII
Printed on Recycled Paper
}
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 115 Seth Goodspeed Way, OsterWIle, MA
Owner: George Anderson
Date of Inspection: January 1, 2000
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon
completion of the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determinedN,explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance,(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal, is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health)
broken pipe(s)are replaced
_ obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
4
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION"FORM
PART A
CERTIFICATION (continued) '
Property Address: 115 Seth Goodspeed Way, Osterville, MA
Owner: George Anderson
Date of Inspection: January 1, 2000
r '
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 the
public health,safety and the environment.'` 4
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 THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of a surface"water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a'salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND
THE ENVIRONMENT:
The system has a septic tank and soil absorption system(SAS)and the SAS is withim100 feet to a surface water supply or
tributary to a surface water supply. '
The system has a septic tank and soil absorption system and the SAS is within a Zone 1 of a public water supply.well
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than"100 feet but 50 feet or more from a private
water supply well,unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER 2
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 115 Seth Goodspeed Way, Osterville, MA
Owner: George Anderson
Date of Inspection: January 1, 2000
D. SYSTEM FAILS:
You must indicate either"Yes" or"No" as to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an 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 1/2 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 Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS: ,
You must indicate either"Yes" or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a desiggflow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
.. .. • .fir, '. ..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B. ; -
CHECKLIST
Property Address: 115 Seth Goodspeed Way, OsterWlle, MA
Owner: George Anderson
Date of Inspection: January 1, 2000
Check if the following have been done: You must indicate either"Yes"or"No"as to each of thefollowing:
Yes No
✓ _ Pumping information was provided by the owner,occupant;or Board of Health.
✓ _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
✓ _ As built plans have been obtained and examined. Note if they are not available with N/A.
✓ The facility or dwelling was inspected for signs of sewage back-up. '
✓ _ The system does not receive non-sanitary or industrial waste flow.
✓ _ The site was inspected for signs of breakout. ` e
✓ _ All system components,excluding the Soil Absorption System,have been located on the site.
✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions of baffles
or tees, material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on: "
✓ _ Existing information. For example,Plan at B.O.H.
✓ _ Determined in the field(if any of the failure criteria related to Part Cis at issue,approximation of distance is unacceptable)
[15.302(3)(b)l•
✓ _ The facility owner(and occupants,if different from owner)were provided with infoii6tion on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 115 Seth Goodspeed Way, Osterville, MA
Owner: George Anderson
Date of Inspection: January 1, 2000
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): n/a Number of bedrooms(actual): 2
Total DESIGN flow n/a
Number of current residents: 2
Garbage grinder(yes or no): No
Laundry(separate system)(yes or no): No; If yes,separate inspection required
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last two year's usage(gpd): 1999-82,000 gals.:1998-84,000 pals.
Sump Pump(yes or no): No
Last date of occupancy: Curreraly occupied.
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gpd(Based on 15.203)
Basis of design flow
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Pumped on 8123198&12129195-per Treatment Plant.
System pumped as part of inspection(yes or no): No
If yes,volume pumped: gallons
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed(if known)and source of information: Unknown
Sewage odors detected when arriving at the site: (yes or no) .No
revised 9/2/98 Page 6of11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 115 Seth Goodspeed Way, Osterville, AM
Owner: George Anderson e
Date of Inspection: January 1, 2000
BUILDING SEWER:
(Locate on site plan) ,
Depth below grade:
Material of construction: —cast iron _40 PVC —other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting,evidence of leakage,'etc.)
1. SEPTIC TANK: ✓
(locate on site plan) r
Depth below grade: 18
"
Material of construction:n• ✓concrete metal Fiberglass Pol eth Polyethylene other(explain)
— — — Y Y -
If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 1000 gal. ,
Sludge depth: I"
Distance from top of sludge to bottom of outlet tee or baffle:- 30"
Scum thickness. 2" z
Distance from top of scum to top of outlet tee or baffle:` 9"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How dimensions were determined: Measuring stick
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.) The baffles were present. The liquid level was even with the outlet invert: u
GREASE TRAP: None
(locate on site plan)
Depth below grade:
Material of construction: —concrete metal Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:` ,
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping: :.
Comments:
(recommendation for pumping,.condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,`etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 115 Seth Goodspeed Way, OsteMlle, MA
Owner: George Anderson
Date of Inspection: January 1, 2000
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to,or 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:
Alarm level: Alarm in working order: Yes_ No—
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
.DISTRIBUTION BOX: None
(locate on site plan)
Depth of liquid level above outlet invert: _
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUMP CHAMBER: None
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order: (Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8oftt
f
SUBSURFACE' SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 115 Seth Goodspeed Way, OsterWle, MA
Owner: George Anderson "
Date of Inspection: January 1, 2000
SOIL ABSORPTION SYSTEM(SAS): ✓
(locate on site plan, if possible;excavation not required, location may be approximated by non-intrusive methods)
If not located,explain:
Type:
leaching pits, number: 1-6'x 6'
leaching chambers, number: _ }
leaching galleries,number:
leaching trenches, number, length:
leaching fields,number,dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology: „
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
The pit had 3'of water on the bottom. The bottom to grade was 8'. There were no signs of failure. "
CESSPOOLS: None
(locate on site plan) A
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(cesspool must be pumped as part of inspection).
Comments: note condition of soil signs of hydraulic failure level of ponding,condition of vegetation,etc
PRIVY: None
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 115 Seth Goodspeed Way, OsteMlle, MA
Owner: George Anderson
Date of Inspection: January 1, 2000
Map: 122
Parcel: 086
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
3r�
� 8
0
,o
/A - aq
AA- ti°1
a
revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,
PART C
SYSTEM INFORMATION (continued)
Property Address: 115 Seth Goodspeed Way, Osterville, MA
Owner: George Anderson
Date of Inspection: January 1, 2000
NRCS Report name
Soil Type
Typical depth to groundwater }
USGS Date website visited
Observation Wells checked
ut
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 38+1- Feet
Please indicate all the methods used to'determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions .
✓ Checked with local Board of Health
. is _ •
Checked FEMA Maps y.
Checked pumping records
Check local excavators,installers a
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. Must be completed)
Using the Barnstable topographic and water contours maps,the maps were showing approximately 38'to groundwater at
this site. The high groundwater adjustment for this site(SDW 253, Zone C, 11199)was 6.5'. `
This report has been prep"and the system inspected and passed as of the date of inspection. ;This report is not a warranty '
or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,
written or implied, relating to the system, the inspection and/or this report.
revised 9/2/98 Page ltofll,,
fk PL 3�IPG 77 LEGEND
U,ho s
LOT 52 LOT' ,53f focus .
L O T 5 99 PROPOSED CONTOUR o w�v ��
N 00 35'50' W
99 PROPOSED SPOT GRADE Re
9b.5 x 98, I — 11 w v
x 989 114.00' ING CONTOUR EXIST Nat�a�.
EXISTING PIT
(TO BE PUMPED & 110 EXISTING SPOT GRADE ' ww
FILLED WX SAND) a
• N P
' TEST PIT o
EXISTING SEPTIC TANK �� w A RSERVICEROUTE 130
TOP OF TANK EL: 98.10 ""�c - 9,t� O o
W EXISTING .W WATER
INV(OUT) EL: 96.77t•
o.7::: o
BENCHMA RK ' ,
J , � NI � LOCUS 'MAP N.T.S.
TOP OF"CONCRETE
R T. BULKHEAD CORNER
EL: , T00.00 ASSUMED)'
oL
•A
r ;
r
:
/
r
w x .99.7
cn v
LOT 54
' }� t GENERAL NOTES:
j x 9 .
98.61 v 1.'ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL
O f x',��p j BOARD OF HEALTH AND THE DESIGN ENGINEER.
f?Otio
jgCJSO M'
MK AND MATERIALS SHALL
UIREMENTS
op 1 ��! 2' OFALL
TH�RSTATE ENV RONMENTAL CODONTORE V,AND ANY APPLICABLE
... ° . ILI LOCAL RULES AND REGULATIONS.
M.
3: THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR
P E BOA HEALTH AND THE
„ 3 'BED TO INSPECTION AND APPROVAL BY THE BOARD ,OF OF
ENGINEER.DESIGN .
I R
HQUSE "` 4'. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
T 5� l HE DESIGN
115� µ TO T
. (# I• ENGINEER BEFORE CONSTRUCTION. CONTINUES.
� I � n •' OM THOSE SHOWN HEREON SHALL BE REPORTED
-. 5 : R
�
� _ f L ELEVATIONS BASED ON ASSUMED DATUM. f
F
Ch
po
r
6, THE DESIGN ;ENGINEER°IS NOT RESPONSIBLE FOR THE FAILURE 0
'4THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF
' HEALTH FOR PROPER INSPECTIONS RING CONSTRUCTION.
7 WATER SUPPLY PROVIDED BY' TOWN WATER-SERVICE.
C2 L 0 T .55 8. THERE ARE NO PRIVATE WELLS,LOCATED WITHIN l 00' OF THE S.A.S.
t 9. ALL AREA DISTURBED DURING CONSTRUCTION SHALL'BE RESTORED
CIL
MAP 1286 10 IT -SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO 2 TO A' CONDITION AGREED UPON BETWEEN OWNER AND S CONTRACTOR.
PARCEL ._ .
_ VERIFY THE
lZD
® THE LOCATION OF ALL UNDERGROUND: UTILITIES, PRIOR TO BEGINNING
19,4,1.4±S.F. CONSTRUCTION.
-WHE
CD
RE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS
• IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE• S.A.S.•
I H EA 255(3).
• � AND REPLACE WITH CLEAN FILL AS SPECIFIED IN 310 CMR
L °55.8 0
� O F MAss9
_90 2Q PAI D E
R8. 1 Jr o PETER T. ✓�
SEPTIC SYSTEM RE R UPGRA
S 00 35'S0 E
� McENTEE
1 CIVIL 115 SETH GOODSPEEDS WAY, OSTERVILLE, MA
L No. 3510-9 Prepared for: Michael Hambly, 115 Seth Goodspeeds Way, 0sterville, M.A
J L �l ! V DOD S�G r_D S V V A / '' FSS/ l �G��` Engineering by: SCALE DRAWN J08. NO.
'' Engineering Works 1"-20' P.T.M. 24-04
12 West. Crossfield Road, Forestdale, MA 02644 DATE CHECKED SHEET No.
���� 4 (508) 477-5313 3/16/04 P.T.M. 1 of 2.
Y / �
NOTE: TO PREVENT BREAKOUT, THE PROPOSED
TOP OF FOUNDATION F.G. EL- 99.2t FINISH GRADE SHALL NOT BE < EL:95.5
EXISTING FOR A DISTANCE OF 15' AROUND THE
EXISTING F.G. EL: 99.7t(EXISTING)
F.G. EL: 99.5t(EXISTING) PERIMETER OF THE S.A.S.
MAINTAIN 2% MIN SLOPE OVER S.A.S.
2-500 GALLON LEACHING CHAMBERS INSTALL,RISER OVER CHAMBER S
INSTALL RISERS OVER INLET & OUTLET INSTALL RISER OVER D—BOX TO /
TO WITHIN 6" OF FINISH GRADE WITHIN 6" OF FINISH GRADE IN SERIES WITH STONE ALL SIDES SHOWN ON PLAN AND SET COVER/S
WITHIN 6" OF FINISH GRADE
L =22' L 13'(MAX)
�s l „ .
4 SCH 40 PVC 4" SCH 40 PVC 10., 2,.,,LAYER:OF 1/8" TO 1/2"
EXISTING u; EXISTING 14 ® S= 1% (MIN.) 6" ® S= 1% (MIN:) ®®®8®�� DOUBLE WASHED STONE
®,®ME3
v 1000 GALLON INV. ELEV.=96.30 INV. ELEV.=96.13 2' EFF. DEPTH �, ®1103
..w., 3/4"-1 1/2"
EXISTING SEPTIC TANK 4' 5.2' 4 DOUBLE WASHED
EFFECTIVE WIDTH 13.2' STONE
INSTALL INLET & OUTLET TEES
GAS BAFFLE TO BE INSTALLED ON INV.EL: 96.77t INV. ELEV.=96.00
OUTLET TEE AS MANUFACTURED BY
TUF—TITE, ZABEL, OR EQUAL D—BOX SHALL BE SET LEVEL AND TRUE TO GRADE TOP CONC. ELEV.=96.8 —BREAKOUT ELEV.=96.5
ON A MECHANICALLY COMPACTED SIX INCH CRUSHED INV. ELEV.=96.00
STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2).
Mime
-BOTTOM ELEV.=94.00
. .SEPTIC SYSTEM PROFILE 4' 1 2 x 8.5' = 4'
5'. MIN. ABOVE BOTTOM OF EFFECTIVE LENGTH = ,25.0'
N.T.S. T.P, EXCAVATION OR G.W.,
NO G.W. ENCOUNTERED LEACHING SYSTEM SECTION
BOTTOM OF TP EL: 88.7
OF
(3) 6" DIA.OUTLETS y�� Mass9��G
1s" 2,. PETER T. J�
DESIGN CRITERIA MCIVILEE
No. 35109
15.5" 6" O r 6„ NUMBER OF BEDROOMS: 3 BEDROOMS f£GISTE���\��c�`�
SS/f/NAl F.�
T SOIL LOG SOIL TYPE: CLASS I
H-10 LOADING 2 DESIGN PERCOLATION RATE: 2 MIN./IN.
r �.�,.-19.2�•-1 MARCH 10, 2004. DAILY FLOW: 330 G.P.D.
D—BOX DESIGN FLOW; 330 G.P.D
N.T.S.
- - -l� PETER T. MCENTEE PE, CSE .
I GARBAGE GRINDER: NO '
I III TP-
LEACHING AREA REQUIRED: (330) = 445.9 S.F.
I I I Elev. Depth .74
®®®® O ®®®® ! --J11 99.2 A SANDY LOAM 0 EXISTING SEPTIC TANK: 1000 GALLON CAPACITY
®®®®®®®®®®® 33^ �IV p 10YR 3/3
N ®®®®®®®®®®® 98.8 5.,
®0�•®®®®®®®®® B
>� SANDY LOAM USE ' 2-500 GALLON LEACHING CHAMBERS IN SERIES
x 9R8 _ _ qq �y A 10YR 5/8
102" —�� l 96.2 36"
C SIDEWALL AREA: 2(13.2' + 25.0') X 2 152,8 S.F.
� r�s°' PaT1'fo E BOTTOM AREA: 1'3.2' x 25.0' = 330.0 S.F.
I
4• KNOCKOUT �, TOTAL AREA: 482.8 S.F.
2O� COVER EXISTING
3 BEDROOM
4^ KNOCKOUT O 4. KNOCKOUT 62" �, a HOuSE MEDIUM DESIGN FLOW PROVIDED: 0.74(482;8) = 357.3 G.P.D.
ura9 «115� 25YN6/6 SEPTIC SYSTEM REPAIR/UPGRADE
4" KNOCKOUT
- — 115 SETH GOODSPEEDS WAY, OSTERVILLE, MA
500 GALLON CAPACITY, H-10 LOADING 88.7 126" Prepared for: Michael Hambly, 115 Seth Goodspeeds Way, Osterville, MA
NO G.W. ENCOUNTERED Engineering by: SCALE DRAWN JOB. NO.
N.T.S
CHAMBERS S.A.S. LAYOUT PERC RATE: <2 MIN/IN. ("C" HORIZON) Engineering Works NTS P.T.M. 24-04
N.T.S. 12 West Crossfield Road, Forestdole, MA 02644 DATE CHECKED SHEET-NO.
(508) 477-5313 3/16/04 P.T.M. 2 of" 2
1