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HomeMy WebLinkAbout0130 SETH GOODSPEED'S WAY - Health 130,�Seth Goodspeed's Ways r Oste' rville P 122 092 1 ` � 0 if iE I Commonwealth of Massachusetts w.+ Title 5 Official. Inspection F®en Subsurface Sewage Disposal System Form Not for,Voluntary Assessments ' __`, ? 130 Seth Goodspeeds Way Property Address Judith Fligg Owner Owner's Name information is Osterville . '� MA 02655 9-26-18 required for every •° page. City/Town State Zip Code Date of Inspection •p..,» C. Inspection Summary „ Inspection Summary: Complete 1, 2,3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: •�" . : System is in good working order with no sign of failure. t 2) System';Conditionally Passes: t ❑'One or more system components as described in the"ConditionalPass"section need to be " replaced or repaired. The system, upon completion/of the replacement or repair, as approved by the Board of HealK 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.- El Y ❑N �❑ ND (Explain below): .r r • , t5insp.doc•rev.7/26/2018• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 4 °', Commonwealth of Massachusetts Title 5 Official Inspection Form* wa p Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments , 130 Seth Goodspeeds Way Property Address C„4 Judith Fligg Owner Owner's Name information is 77. required for every Osterville MA 02655 9-26-18::� page. City/Town N 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. A. Inspector Information g�g Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA, 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l 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 theproperty 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 9-26-18 Inspector's Signature Date The:system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 l Commonwealth of Massachusetts Title 5 Official Inspection Form i i�l Subsurface Sewage Disposal System Form Not for Voluntary Assessments 130 Seth Goodspeeds Way ' Property Address Judith Fligg Owner Owner's Name information is Osterville '_ MA 02655 9-26-.18 required for every "• page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) i ; , 2) System Conditionally Passes (cont.): , ❑ Pump Chamber pumps/alarms not operational. System will•pass with Board of Health approval if ' pumps/alarms are repaired.- El 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 ❑W °❑ 'ND•(Explain below): INS obstruction is removed ' ❑ Y ''❑N ❑`;Nb (Explain below): El 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 ON ❑ ND (Explain.below): ❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below): 3) Further Evaluation is Required by the,Board of;Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the&system is failing to*Orotect'pubiic 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: 1.7• t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts _ Title 5 Official Inspection Form ial Subsurface Sewage Disposal System Form -Not for Vol u nta ry.Assessments 130 Seth Goods eeds Way Property Address Judith Fligg Owner Owner's Name information is Osterville MA 02655 9-26-18 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 11 of a public water supply. ❑The system.has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: ; 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No i ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 1 ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts a 3 Title 5 Official Inspection Foem X it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Seth Goodspeeds Way Property Address Judith Fligg y Owner Owner's Name information is Osterville MA 02655 9-26-18 required for every ' page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 3 ►a_ •4) System Failure:Criteria Applicable to All Systems: (cont.)• , Yes No F, , . b 'Static liquid level in the distribution box above outlet inverttidue to an overloaded or clogged SAS or cesspool Liquid depth in cesspool.is less than 6" below.invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: t ❑ ' ® ,Any portionlof 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. ❑ ® 4 Any portion` of a cesspool or privy is within a Zone 1 of a public water supply well: El ® Any portion of a cesspool or'privy is within 50 feet of a private water supply well. ® Anyt portion of a cesspool or.privy is less than 100 feet but greater than 50 feet from a private water Isupply 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.], 1 The system is a cesspool servinga facility with a,desigQ flow of 2000® gpd- 10,000 gpd: r `® ` The system fails. I have.determined that one or more of the above failure criteria ezist'as described`in 31 b 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. -+ t 5) .l arge Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 god to 15,000 gpd:. - y -For large systems,jyou must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. + + Yes No ❑I ❑ 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 r� ;w Title 5 official Inspection Form n _ i I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 130 Seth Goodspeeds Way Property Address Judith Fligg Owner Owner's Name information is required for every Ostefville MA 02655 9-26-18 page. y 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, ® ❑ 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? ® ❑ i 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? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I - Commonwealth of Massachusetts > FE - .•:f�E°,.;f x - ;.; Title 5 Official Inspection Form.- . : r -i Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 130 Seth Goodspeeds Way _ Property Address <. Judith Fligg Owner Owner's Name information is required for every Cistefville MA 02655 9-26-18 - page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms(actual): 2 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 Description: Number of current residents: 1 Does residence have a garbage;grinder?;f. ..j ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) ! ' w Laundry system inspected? ❑ Yes ® No Seasonal use? - ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? t. ,, ❑ Yes ® No Last-date of occupancy: ,.; ,; 9-2018 Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 c Commonwealth of Massachusetts y Title 5 Official Inspection Form IV ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Seth Goods eeds Wa P Y Property Address Judith Fligg Owner Owner's Name information is required for every Osterville MA 02655 9-26-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Watertreatment 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--not pumped last 5yrs Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 f Commonwealth of Massachusetts r ,; =, .. • ; <,...• • _ Title 5 Official Inspection Form ' ? c�t Subsurface Sewage Disposal System Form—Not for Voluntary,Assessments 130 Seth Goodspeeds Way Property Address r Judith Fligg Owner Owner's Name information is required for every Osterville ? MA 02655 9-26-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: Septic tank, distribution box, soil absorption system Single cesspool , „ t, .• ❑ f Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) i 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 ❑I Tight tank.-Attach a.copy of the;DEP-approval. ; Other(describe): Approximate age of all components, date installed (if known) and source of information: 2012 . Were sewage'odors detected:when arriving at the site? ,❑ Yes ® No 5. Building Sewer(locate on site plan): , 2411 Depth below grade: ''f ' 'feet ' e Material of construction: } ' ❑ cast iron ® 40 PVC ❑ other(explain): " Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form '110iMl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r r/ 130 Seth Goodspeeds Way Property Address Judith Fligg Owner Owner's Name information is required for every osterville MA 02655 9-26-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 121 1 Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 ram" Commonwealth of Massachusetts Title 5 Official Inspection Form_ '-. . - .. " it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 130 Seth Goodspeeds Way At Property Address Judith Fligg Owner Owner's Name information is -, required for every Osterville MA 02655 9-26-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) } .• 4� • -. 7. Grease Trap (locate on site plan): , Depth below grade: feet ' Material of construction: • i ❑ 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.): R 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.,712612018 C'. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18. Commonwealth of Massachusetts y Title 5 Official - Inspection Form Y>1 al Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Seth Goodspeeds Way Property Address Judith Fligg Owner Owner's Name information is Osteryille = MA 02655 9-26-18 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): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence!of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts ,r.; Title 5 Official Inspection _Form _ ! 'A Subsurface Sewage Disposal System Form-Not for,Voluntary.Assessments f a - �1._�; ,> 130 Seth Goodspeeds Way r f Property Address Judith Fligg F + Owner Owner's Name information is required for every Cisterville MA 02655 9-26-18 ~ 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 Alarms in working'order:" ` ''' :❑ Yes` ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil,Absorption System (SAS) (locate on site plan, excavation.not required): If SAS not located, explain why: Type: ❑ ,�.» - leaching pits' "4 - ,r. , number: . .. ❑ leaching chambers number: ❑ leaching galleries -number: ® leaching trenches number, length: 2--30'x3' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/2612018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18. Commonwealth of Massachusetts Title 5 Official Inspection Form lal Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Seth Goods eeds Way Property Address Judith Fligg Owner Owner's Name information is required for every Osterville MA 02655 9-26-18 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.): Leach field in good working order with no sign of back-up into d-box or,surrounding stone. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert - Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts IJ . r fw Title 5 Official ,Inspection Ford - r-li Subsurface Sewage Disposal.System Form:-Not for Voluntary Assessments rV 130 Seth Goodspeeds Way y .: Property Address _ Judith Fligg Owner Owner's Name information is �.. , •' required OSteNllle for every MA 02655 9-26-18• R page. City/Town state Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materiais 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 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 ^., Commonwealth of Massachusetts - Title 5 Official Inspection Form )i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Seth Goodspeeds Way rl Property Address Judith Fligg Owner Owner's Name information is required for every Osterville MA 02655 9-26-18 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 r y1 f3, t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts f . Title 5 Official- Inspection Ford ��. ', Subsurface Sewage Disposal System Form -Not,for Voluntary Assessments 130 Seth Goodspeeds Way _ R Property Address Judith Fligg , Owner Owner's Name information is MA 02655 9-26-18 required for every OStervllle - ;,��,•. • '- `' page. City/Town State Zip Code Date of Inspection D. System Information cont: s 15. Site Exam: ❑ Check Slope r, ❑ Surface water ❑ Check cellar n ❑ Shallow wells ,F Estimated depth to high ground water: - r j. 12'- feet ` Please indicate all methods used to determine the high groundwater elevation: ® Obtained from system design plans on record_,,- t If checked,date of design plan,reviewed:. ' Date ® Observed site (abutting property/observation,hole:within 150 feet of SAS) ® Checked with local Board of Health - explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You imust describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 s� Commonwealth of Massachusetts Title 5 Official Inspection Forts' 16) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 130 Seth Goodspeeds Way Property Address Judith Fligg Owner Owner's Name information is required for every Osterville MA 02655 9-26-18 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 ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 130 Seth Goodspeeds Way Osterville, MA 02655 Owner's Name: Paul Flanagan, Executor Owner's Address: i ""' Date of Inspection: September 30, 2006 c w Name of Inspector: (Please Print) James M. Ford ' u� r Company Name: James M. Ford N) Mailing Address: P.O.Box 49 p t- Osterville,MA 02655-0049 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 4of Further Evaluation by the Local Approving Authority . Inspector's Signature: Date: October 9, 2006 The system inspector shall subs 't a copy 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 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A -,CERTIFICATION (continued) Property Address: 130 Seth Goodspeeds Way Osterville, AM Owner: Paul Flanagan, Executor Date of Inspection: September 30, 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or breakout or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed 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 I Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 130 Seth Goodspeeds Way Osterville, MA Owner: Paul Flanatran, Executor Date of Inspection: September 30, 2006 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 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than'100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a'DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from.that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 130 Seth Goodspeeds Wav Osterville, MA Owner: Paul Flanagan, Executor Date of Inspection: September 30, 2006 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 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone I of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 130 Seth Goodspeeds Way ' Osterville, MA Owner: _ Paul Flanagan, Executor Date of Inspection: September 30, 2006 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ _ Pumping information wag 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 Page 6 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 130 Seth Goodspeeds Way Osterville. MA Owner: Paul Flanagan, Executor Date of Inspection: September 30, 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for.example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [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: Unknown COMMERCIAL/INDUSTRIAL p 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 Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): 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: Installed on 6130177-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 130 Seth GoodWeeds Wav Osterville, MA Owner: Paul Flanagan, Executor Date of Inspection: September 30, 2006 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: 28" 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 ate— Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: _ Measuring stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.)'. Tees were present. The liquid level was even with the outlet invert There did not appear to be any si ns of leakage 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 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 130 Seth Goodspeeds Way Osterville, MA Owner: Paul Flanagan, Executor Date of Inspection: September 30, 2006 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) Commnents (note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 130 Seth Goodspeeds Way Osterville, MA Owner: Paul Flanagan Executor Date of Inspection: September 30, 2006, SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I -6'x 6'(1000 gall ' 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 pit was drv. The scum line was approximately 3 S' up from the bottom There did not appear to be any signs of failure The cover was Y below grade. The bottom to grade was 91 . CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no)`. Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments.(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 130 Seth Goodsgeeds Way Osterville, MA Owner: Paul Flanagan, Executor Date of Inspection: September 30, 2006 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. - d f 10 �. Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 130 Seth Goodsgeeds Way Osterville, MA Owner: Paul Flanagan, Executor Date of Inspection: September 30. 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 35 +/- feet, Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 35'+/-to ground water at this site. This report has been prepared only for the septic systenz and components described herein. This septic system has been 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 septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 9oc Permit# Health Division UA ci, cb. .APO. 3 2001 Date Issued Conservation DivisionS'o ����/�G Fee Tax CollectorG V. Treasur Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address /3® Loo Village _d S74 yf 11-e r Owner 11L V Cf f'1 Address ��o'�F,/ iev j.✓/ Telephone �9�f Permit Request r112_ S d` Zr^ Ly Square feet: 1st floor: existing 1/ proposed 4/7 i 2nd floor: existing proposed Total new Valuation i ,,G� Zoning District Flood Plain Groundwater Overlay Construction Type Vo 2-6^ 10 " 60 Lot Size 17. �� Grandfathered: O Yes O No If yes, attach supporting documentation. Dwelling Type: Single Family X Two Family Cl Multi-Family(#units) Age of Existing Structure Cf Historic House:, ❑Yes , ❑ No On Old King's Highway: 0 Yes ❑No Basement Type: )I Full O Crawl ❑Walkout ❑Other `Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 0 y Number of Baths: Full: existing dh-e new -e Half: existing new Number of Bedrooms: existing±U✓a new Total Room Count'(not including baths): existing PfOA 4 new Va First Floor Room'Count TO\ Heat Type and Fuel: V Gas ❑Oil O Electric ❑Other Central Air: ❑Yes 34 No Fireplaces: Existing h e, New Existing wood/coal stove: 0 Yes ❑No Detached garage:O existing ❑new size Pool: 0 existing ❑new size Barn:Cl existing ❑new size Attached garage:Xexisting ❑new size l a Shed: existing ❑new size 9X Other: Zoning Board of Appeals Authorization O Appeal# Recorded O TU OF.;B'�ABLE (SEWAGE# LpCpi'hZQN ��� ASSESSOR'S OT �FSTALLEtt`$FtAli►F &PIJONE TZ1 SEMC LIaAC1IIl�iG FACId ' 'tom) re Cs £5ie) �36x 3 No.oi�sooi+�s 33uu:v orb owl PERMITDATE. _ 00heMNCE'DATE:' Sep Drstance Bet�reetti:�e Feet Maximum Ad�ustecl G aundwater Table to the Bottam of I,eactiirc$Facility Prorate g4►atarS tip ptyell asdI,eacag Facht�► t :as►Y,uells exist Feet oa s�ca or.anttun 20fi feet of leaelnng fac. ccg) Edge o£Wetland and 9,,apy(if any wetlands exist Feet v�nthtn 3IX1'he n lung fa ) l`,c C.. ,�c:CdC it 1 3 5� -l� 33 ' -1- �s- �6 4-5-- (0 " I TOWN OF BARNSTABLF _k CATION f d S��/ ��/�� SEWAGE# VILLAGE t16Pl1/�J Q ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. � SEPTIC TANK CAPACITY LEACHING FACILITY:(type) %/(�����5" (size) 3q NO.OF BEDROOMS OWNERfl ��� PERMIT DATE: /'61► � 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 fa ' ' ) Feet FURNISHED B r r g k a 3i. 5 y Ll S 5d .5 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftpliration for -Misposaf 6pstem Construction permit Application for a Permit to Construct( ) Repair(�) Upgrade( )� A andon( ) El Complete System El individual Components Location Address or Lot No. 3 4 (10 ner's Name,Address,and Tel.No. Assessor's Map/Parcel �} 6 Installer's Name,Address,and Tel.No. Designer's Nam ,Address,and Type of Building: 1—1 cr-1-2-- Dwelling No.of Bedrooms^ r Lot SizejqT�^7 sq.ft. Garbage Grinder( ) Other Type of Building (�.Q$�C��Pi1/► No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ZZ-0 gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enviro ntal Code not to place the s stem in operation until a Certificate of Compliance has been issued by this Board It . S' d Date Application Approved by Date Application Disapproved Date for the following reasons Permit No. ZD IZ_— 5/1( Date Issued 441%1701Z a No. 70 I I Fee *16-6 6V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS application for Misposal ,6pBtem Con's rUttion permit x Application fora Permit to Construct( ) Repair(�). Upgrade ) Abandon( ) .0 Complete System ❑Individual Components Location Address or Lot No. j(� �j {� qao ner's Name,Address,and Tel.No. Assessor's Map/Parcel J - 15; 2 lu4Q F 1 Installer's Name,Address,and Tel.No. Designer's Nam ,Address,and Tel: ld0 --:3`o 0 a s T-1 ca i h T ,m rr eu c Type of Building: J 1-1 q J-2--L- Dwelling No.of Bedrooms 1.4- Lot Size j'-�'Z3"� sq.ft. Garbage Grinder( ) Other Type of Building-2.QSt?d4 t iT No.of Persons Showers(� ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A rSr Description of Soil Nature of Repairs or Alterations(Answer when applicable) V I r' i Date last inspected: 9 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 Environm ntal Code a not to place the system in operation until a Certificate of Compliance has been issued by this Boardp e it / t S'gn d Date Application Approved by Date, $ �z Application Disapproved Date for the following reasons . f Permit No. e-70l Z Date Issued !V,57j'/201 --------------------------------------------------------------------------------------------------------------------------------------- Th E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )byX C h at 0 Y has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.�11� 3t y dated lo�h 201� Installer I(('�d/1 E_X('G�11 `IQ � �1� Designer r-Y-g4/-e d� ��Q t�,ip v' #bedrooms Approved design flow 2-2-0 gpd The issuance of this permit shall not be construed as a guarantee that the system will functio as desi n d. Date J ���, Inspector ------------------------------f--------------------------------------------------------------------------------------- ----------------- No. 1 Z'- ��"I Feel THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Mispo9al 6pstem Construction permit Permission is hereby granted to Construct( `) RepairIc Upgrade( ) Abandon( ) System located at 3 Y1 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date 1 ZO 1-L . Approved by N cr S I Town of Bd nstaie. P# �THE F Department of Regulatory Services- Public Health Division. BateBEA — r 200 Main Street,Hyannis MA 02601 Time_ tJ- Fee Pd. Date Scheduled . • - 4 ,soil ,Suitali lity Assessmejit for.,Se, aDisposal Performed By: ` wy U� ' Witnessed By: - LOCATION & GENERAL INFORMATION p Location Address .130 ce- 600VSPQ�W ' �I� OA. wner'sNari>e Fill 66/ L ���H'�i/�J Address SA Assessor'sMap/P4rcel: 1�Cq Engineer's Maine , f`fZ�` NEW CONSIRU�i ION REPAIR Telephone# �D$ Land Use I`u 1�C� !�1 Slopes Surface Stones Distances from: Open Water Body f'00 ft Possible Wet Area ?�D_ft' Drinking Water Well ft ' Drainage Way. > j f. Property Li ft Other ft SKETCH:($treet name,dimensiods'of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) 0 - .. P ' / • •. /�C�/0. FENCE_...• so.z aN oo - - /eJ 552•Z225 W _ .- ; 6p J Q .. ..vr i.:T A-,.• NJO _ ./ TO�f130 �'<ST EbST lE 1 }0.43 � f DECK i /. c /46/)g/Cr 0992 n,,p�'`.� „Q N '� H \ aq �D I _, ASPHALT 60J I RC m. ` DRIVEWAY .;J _ • I _ / _ QD _ //___� VER 61 182.30 559'25'af . Depth to Bedrock Parent material(geologic) GCG 5�. , Depth to CrroundwaKer. Standing Water in Hole:* I Weeping from Pit Face n a Estimated Seasonal Vigh Groundwater ��Q i DtTERMINATION FOR SEASONAL kiIGRYA. 3� TOLE Method Used: in. Depth to sail tttOttlas: In: Depth (!bperved standing in obs.hole: ---in ©roundwnter AdJuBtment it- Depth toiweeping from side of obs=hole: i _ Adj. Aetor,,...,.a- A�,(3roundwaterl evel.,,,a Index Well# �. Reading Date - Index Well level i PFRCOLATI�ON TEST . Date o. Tli11iC•���. Observation l I Tltrie at Hole# Time at 6" -- '- Depth of Pere,' Time(9"-6") - Start Pre-soak Time.@ / End Pre-soak �Z :i i a 1 � • !ice i f Rate Min_11nch Site.Suitability Assessment Site Passed X Site Failed; Additional Testing Needed(YIN) Observation Hole Data To Be Completed on Back Original: Public k,e'alth Division -- ***If percolat ibn test is to be condiacted within 100' of wetland,you must first notify the Barnstable C4nservaticn Division at least one (1) week prior to beginning. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel 'PW-� /l 3`V l23 G �. fund 2• bly DEEP OBSERVATION HOLE LOG Hole# �Y Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistenc %Gravel) A 1. tj 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 Hori Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. ra I Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year boundary No /Yes Within 100 year flood boundary No_✓ Yes Depth p of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervio s glaterial exist in all areas observed throughout the area proposed for the soil absorption system? S If not,what is the depth of naturally occurring pervious material? Certification /� I certify that on d "C (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 require ' i expertis and exp rienc escribed in 3,10 CMR 15.017. Signature Date L L y Q:\SEPTIC\PERCFORM.DOC Town of Barnstable �t Regulatory Services t o„ Thomas F. Geiler,Director BMWMBLE. : Public Health Division 13 9. A � Thomas McKean,Director FD Mp'l 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: 06 V Sewage Permit# Assessor's Map/Parcel Installer&Designer Certification Form Designer: U 4 o l ` Installer: Address: P� Address: t'V 4 On /2- A Ee?`Aa4W1d1a was issued a permit to install a (date) (instal er) _ septic system at 1?2 S8-r4 Good d S WA, based on a design drawn by (address) Z1, dated /0 t f) Z (designer) X I certify that the septic system referenced above'was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow.. Stripout (if required�,0, ' d and the soils were found satisf ry. ��, g4c�9 c DAiREN G A 0 ME 'ER rn (Installer's Signature) o. 1140 . 0 q' (TA (Designer's Signature) ( ix esigner s ere) PLEASE RETURN TO B STABLE PUBLIC HEALTH DIVISION. ERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. q:\office forms\designercertification form.doc TOWN OF BARNSTABLE ,LOC.ATION 130 S l�P �1 0beSPU, R 1,4q SEWAGE# / (I-' E �S�e,(v,llt ASSESSOR'S MAP&PARCEL /AA " 1� �h►! "INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY WO LEACHING FACILITY:(type) (o)(L t"+T (size) NO.OF BEDROOMS 3 // OWNER JAn PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY :r/1.tpGyTi m - �Dr� :4 f I ` V a. / 33 i� yj ag )19 Vol -1;O=CATION SEWAGE PERMIT N0. .. •'VIL LAG E INSTA LLER'S ,.N, A�ME & ADDRESS B UI'LDE R OR OWNER DATE rPERMIT ISSUED � � 7 DATE COMPLIANCE ISSUED �` ^� 4 I t � E ��� :Z)� � �'�j 2 � I�� r -' � �c f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION o� RECEIVE® . MAP' Z2 PaRclo �-` AUG 0 9 2004 ..� ® � ---tQ ,,,,, TOWN OF BARNSTABL€ TITLES HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 130 Seth Goodspeed Way t Osterville 4 Owner's Name: Vivian Kallenbera Owner's Address: 4, Date of Inspection: Name of Inspector:(please print) W i 1 1 i am E_ •Robinson Sr. + Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1089 r- Centerville, MA Telephone Number: (SOB) 77S-8776- 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: t.�Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: :�ge ,T �,,,.,�d�� Date: �•^. g�D LJ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be seat to the system owner and copies sent to the buyer,if applicable,and the approxing 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 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). Property Address:__3_,In St t h C;nnrl—pt r7 Wa S� ; �lstervi> > P Owner: Date of Inspection: 6 / Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy em Passes: I1 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. Sy em Conditionally Passes: O e or more system components as described in the"Conditional Pass"section need to be replaced or repaired. a 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 s tic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exh bits substantial infiltration or exfrltration or tank failure is imminent.System will pass inspection if the existing tank s replaced with a complying septic tank as approved by the Board of Health. •A metal sep c tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating th the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or obstructed pip s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Bo of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system requ' ed pumping more than 4 tunes a year due.to broken or obswucted pipe(s).The system will pass inspection if(with a roval of the Board of Health): broken pipe(s)are replaced obstruction is n=vcd a; ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 130 Seth Goodspeed Way Osterville Owner: Vivian Kallenberg Date of Inspection: . ;Z—,,Z 'Y3v! 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. S stem will r fart unless the Board of Health(and Public Water Supplier,if any)determines that the syste 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 su face 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 froal a riv ate water supply well•• Method used to determine distance -This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform acteria and volatile organic compounds indicates that the well is free from pollution from that facility and e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other f ilure criteria are triggered.A copy of the analysis must be attached to this form. 3. Othr r: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 130 Seth Goodspeed Way Osterville Owner: Vivian Kallenberg Date of Inspection: 7- -L y—b 4 D. ystem Failure Criteria applicable to all systems: You ust indicate"•yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow 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 I00.feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. _. .Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility and (lie 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/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. arge Systems: To b considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 hpd- You ust indicate either"yes"or"no"to each of the following: (11e f flowing criteria apply to large systems in addition to the criteria above) yes n the system is within 400 feet of a surface drinking water supply the system i within ace i water supply y s t htn 200 feet of a tributary to a surf drinking the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped one 11 of a public water supply well If you have answered"yes"to any question in Section E the system is coasidered a significant threat,or answered "yes"in Se • n D above the large system has fated.The(mmer or operator of arty large system considered a significant threa under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The syste owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 130 Seth Goodspeed Way Osterville Owner:_y nberg Date of Inspection: —0 of Check if the following have been done.You must indicate' es"or"no"as to each of the following: Yes No �P mping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? _ Y P P P _ Has the system received normal flows in the previous two week period? ave 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 _ t✓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 Page 6 of I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 130 Seth Goodspeed Way Osterville Owner: Vivian Kallenbera Date of Inspection: ? FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): j— Number of current residents: Does residence have a garbage grinder(yes or no): D Is laundry on a separate sewage system(yes or no):mac)[if yes separate inspection required] Laundry system inspected(yes or no):,f.- Seasonal use:(yes or no):_1� s Water meter readings,if available(last 2 years usage(gpd)): 2003 — 24, 0 0 0 Sump pump(yes or no): t/O 2002 — 24,000 Last date of occupancy: y A COMMERCIA USTRIAL Type of establis ent: Design flow(base on 310 CMR 15.203): gpd Basis of design fl w(seats/persons/sgft,etc.): Grease trap pres t(yes or no):_ Industrial waste olding tank present(yes or no):_ Non-sanitary ste discharged to the Title 5 system(yes or no): Water meter adings,if available: Last date of ccupancy/use: OTHER escribe): GENERAL INFORMATION Pumping Records Source of information: q Was system pumped as part f the inspection(yes or no): d If yes,volume pumped:__gallons--How was quantity pumped determined? Reason for pumping: T �Y P�OF SYSTEM peptic 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/Altemative 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 own)and source of information: Were sewage odors detected when arriving at the site(yes or no):AO 6 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: 130 Seth Goodspeed Way Osterville Owner: Vivian Kallenberg Date or inspection: BUILD G SEWER(locate on site plan) Depth be w grade: Material of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comme is(on condition ofjoutts,venting,evidence of leakage,etc.): SEPTIC TANK:Alocate on site plan) Depth below grade: 3 Material of construction: !/concrete metal fiberglass_polyethylene _other(explain) If tank is metal list age:U Is age confirmed—by a Certificate of Compliance(yes or no):_(attach a copy of certificate) 4 1 j Dimensions: r a of 4. 17 L' Sludge depth:_ �._41 Distance from top of sludge to bottom of outlet ice or baffle:_ Scum thickness: —/ Distance from top of scum to top of outlet ice or baffle: Distance Gom bottom of scum to bottom of outlet tee or baffle. ' How were dimensions determined:- (S P eye.. C Q 4,C-A � Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage✓,etc.): d� � low l U a O a f � v dam- ��u GREASE TRAP:_(Io atc on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene_other (explain): _ _ Dimensions: Scum thickness: Distance from top of s um to top of outlet tee or baffle: Distance from botto of scum to bottom of outlet tee or baffle: Date of last pumpin . Comments(on pun ing recommendations,inlet and outlet ice or baffle conditio:t,structural integrity,liquid levels as related to outic invert,evidence of leakage,etc.). 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 130 Seth Goodspeed Way Qsterville Owner: Vivian Ka 1 1 enberg Date or lnspectioo:_ 7—;9—b V TIGHT or HOLIB ING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grad : Material of consin ction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: allons/day Alarm present(y s or no): Alarm level: Alarm in working order(yes or no): Date of last pu ping: Comments(c ndition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓{if present must be o ened locate on site plan) P )( P ) 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.): �® e6 PUMP CHAMBE (locate on site plan) Pumps in workin order(yes or no): Alarms in worki order(ycs or no): Comments(not condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 130 Seth Goodspeed .Way Osterville Owner: Vivian Kallenberg Date of Inspection:_'7— 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: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): )2A1� CESSPOOLS. (cesspool must be pumped as part of inspection)(locate on site plan) Number and con I uration: Depth—top of li id to inlet invert: Depth of solids la er. Depth of scum lay r. Dimensions of ces ool: Materials of cons ction: Indication of groun water inflow(yes or no): ' Comments(note co dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:—(locate on site plan) Materials of cons ction: Dimensions: Depth of solids: Comments(note c ndition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 130 Seth Goodspeed Way Osterville Owner: Vivian Kallenberg Date of Inspection: 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. a�G �3 10 Page l 1 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 130 Seth Goodspeed Way Osterville Owner:-Vivian Kallenb_er Date.of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells J Estimated depth to ground water 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: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: xle 11 ®r—; .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT f9.ti��- ✓s�....OF... . 2 t -.. ....................... Appliration -for 43- hipwial Evrkii Tontitrurtion Vatuff Application is hereby'made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal Syst .__...•_._.__ _'--'-' _ _...___i... .................................. .....0 .. f_.. ..... ...............................................................V . /�G />J/y L a ion-Address , or Lot No. Owne 9 dress `}fZr_ Installer Address Q Type of Building %%% Size Lot-----I/-__`2_..!!�-,4__Sq. feet U Dwelling—No. of Bedrooms-________ .............................Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building No. of persons____________________________ Showers — Cafeteria dOther fixtures __ ````r` -- ------- -------------------------------------------- W Design Flow...........S _ ......................gallons per person per day. Total daily flow---- _ _4� ............... ........gallons. WSeptic Tank—Liquid capacit_j&��.gallons Length________________ Width......-......... Diameter__-____-_-____ Depth.-.______-_---- x Disposal Trench—No. .................... th-------------------e tal Length-__..__.___._.._ _ To leaching area--_-_______-.______sq. ft. Seepage Pit No.�' '�- '����� ��` _g t 1 _ r=--�- ------- achin trea------------------sc ft. z Other Distribution box ( Dosing tank �77 Percolation Test Results Performed by_________________________________________________ a ----------=-------------- Date---........-------------------------.... a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-.-----------..._._____- G� Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water__-.._-____-______--__- -----•----- -• r - ---------- ------ - [�- - - ------- - O Descri Description of Soil -� _ __, '-- ------------------ ----F.__�� �g� x P d, •- c., -------------------- - - � ��s 0 :•.•.--.•----------------------------------------------------------------------------------------------------- --------- U Nature of Repairs or Alterations—Answer when applicable----------- Q-0. .... ------ ---_-- �,. 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 bo rd of health. / ` Signe _ .. - -� �. ate ApplicationApproved By...............................------------------=---------------------•---•-•--•--•-•---•----•-- . ------------------ Date Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------- .................................. ------------------------------------------------------------------------------------------------------------------------------•---------•--..--------------------•---- Date Permit No_________________ ��— ---•----••---•-----•-------------------- Issued---- ----�-' ------------------------------------------ Date No. V` FEE...I...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,,,, w AVP trafiun -for 13,hip int Works Towitrurtion Prrutit Application is hereby'made for a Permit to Construct ('�'") or Repair ( ) an Individual Sewage Disposal System at ----------------------------------------=•----•-=----:.....---•-•----._...--•----••--/•-----• •...._.....--•-----•••-•-•------•=----...-•-••-•-•--••----•-•---------_._...•-•--•---•----•------ Location-Address ! or Lot No. Owner t / Address ^` W .a�c n 00 e i - .� .•�ti{��t �r Installer Address Type of Building Size Lot........*_............!<_.Sq. feet U Dwelling—No. of Bedrooms---------- �______________________.-_ -----Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q Other fixtures -_✓r" '" '""'"' ----------------------------------------------------------------------------------------------------------------------------------------- W Design Flow---------- -_f?______________________gallons per person per day. Total daily flow______2 41 ��.___._.__.._.___....._...gallons. 9 Septic Tank—Liquid capacity f.(�'�"gallons Length________________ Width_.............. Diameter---------------- Depth.-_.----__.-.... x Disposal Trench—No. ......... Width______________---------------- Length.-_-__-_ Z Total leaching area----..-._---.._____sq. ft. Seepage Pit No._!.�?.'_` f`____ Diamet ?`°............ %D pth b'elc�iw�ifi t`"?` �"C° -tal'leachi g area..« -_-_--__.sq. ft. Z Other Distribution box ( )' Dosing tank ( ) " t + " `�0 .r IF Percolation Test Results Performed by-------------------------------------------------------------------------- Date_-___.__.__-.----•_---..--.----------.-. Test Pit No. 1----------------minutes per inch Depth of Test'Pit-.._-_-___-__.____-. Depth to ground water------------------------ (14 Test Pit No. 2................minutes per inch Depth of Test Pit.-__--_-_..._____-_ Depth to ground water._._.-.----_.--.-----._. . . I�' 4 w 4 + «�___ J - ` O Description of Soil----_�*'. -- . ------ 'r -- - --- w � lJAii . ,. ---o-noj.14-------6"t 7 W -.•-------------- ------------ ------- -------------------------------------------•---------------•------------------ .---.--- ------ txj Nature of Repairs or Alterations—Answer when applicable.-._-_-_..._- ........................................--------------.......----------......... Agreement: Y The undersigned agrees :.to install 'the aforedescribed Individual Sewage Disposal System-in accordance with the provisions of Article \I 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. +.:,_..•l ------ --=-=-`--------/!'r,.+ ................................ Date ApplicationApproved By----------------------------------------------------------=------------------------------------ Date Application Disapproved for the f olloui ng reaso- ----------------------------_.__-----------------------------------------------------------------------•------- -------------------------------------------------------------------•----•---------:----=-------------.._...-.--•------•-----•--------------------------------------------------••-•-----•-------------- Date PermitNo......................................................... Issued...................... ................................. Date THE COMMONWEALTH OF MASSACHUSETTS —M- BOARD OF HEALTH .............................................. Cnrrti� r�t�r >nf �uut�li�nrr THIS IS TO CERTIFY, That/the,Individual Sewage Disposal System constructed ( `) or Repaired ( ) ( r/ Installer �; /% � at-------=..�-� �;' f .C� t �./ ----e'er-- •-----r--•-- ------•------•---------------- ----•-- -------- �--:------------------------ _ _ -------------- has Ibeen installed in accordance with the provisions of . j .of The State"Sanitary Co as escrib in the application for Dis oral Works Construction Permit No:__ _._ dated_._.._ "'`.. "'.jam_ ............ P t ------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT TIME SYSTEM WILL FUNCTION SATISFACTORY. DATE.................... Inspector---------------------------------------------------•----------------•••----•-----•- THE COMMONWEALTH OF MASSACHUSETTS �J f' BOARD OF HEALTH .......�. ..... r OF..... _� . .. f% .....r-..�.......�...-.�.............................. . ..._... .- FEE_........................ • �i����tt� �rk,� �1Q�t�t��C�t>QIt �rr�tit r R� Permission is hereby granted......... . ---`-�------_._.__ ���`-r"._.. Y--'.`-� to Construct (,KorJ Repair ( ) an Individual,,Seva age Disposal System/ atNo. .....................................•.��r d _.`, ----�'� ��------ -- ---Y-_. •---- ------•-�y--- 1 �..-(wry C;•, Greet j as shown on the application for Disposal Works Construction Per No...... .:.......... Dated---- *'.-.�"".`.._... �.__.___. Board of Vealtir DATE-----------------------------------------------------------------••---•-----•-_. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ° 10 V ',} �Al 1 , � •� � f\ b_ 9 „? i • At RICHARD t A. BAXTER No.2 4038" , 0 C-"TI P 4 T"A tTN6 f0u i,D�,r't G N 51.1o,Av1.1 PLAw RsP,EVEW, x F`. NSR Q OW 4COA,%PL%eS W I TN TWS: S I DE_.LI► e: A a.43a O S tiZE4UICEME ,� 'AhJD SET�IGIC a,tT`s OF TNT '• B A,ATE W. W%(E'K I4•!C. r � ' REGIS'�6.� 9.AIJp -5ti�,VsYoRS�; TWIS D'�.Aw IS LJOT BASer) . •064 AN - OSTEfZV1LL.fe o M(aSS.; o-' lW-gMLJAMENT SU¢VE'y( 4 7iNE olr ,5ETS 5140 APPLI GA -T- , . ; T 6fi � USED Tp. DETEe.M i alb LOT Ll WeS C. P E V�I I(D E �,EdS a L ° A 8 4y t] OSTERVILLE LEGEND PARCEL ID: 122/74 r" PROPOSED CONTOUR � . y ® PROPOSED SPOT GRADE —— 98 —— EXISTING CONTOUR 6" i�2, 0O �yS + 96.52 EXISTING SPOT GRADE `S�'• PARCEL ID: F ,9 W— EXISTING, WATER SERVICE. 60.260.20 122/75 1� ti o LOCUS ® TEST PIT 6G`L o GOODS ED'S 1 WAY ROUTE 28 , It . 60.3 10"SPR ; 0.30 O�OS Sy I, LOCUS MAP D � �Or , PA46 �9 " LOCUS INFORMATION TBM: / PLAN REF: 311/77 , . �cj`L E� LEV=61.0 �6 TITLE REF: 22417/136 PARCEL ID: ,,, „ PARCEL ID: MAP 122 PAR. 92 122/93 .4 Y ZONING: "RC" FLOOD ZONE: "C" vent �- COMMUNITY PANEL: -250001-0015-C DATED:08/19/85 EXIST. LEACHPIT �F �p, X60.7 ; PARCEL ID: SEPTIC .SYSTEM i EXIST. 1,000G o SEPTIC TANK 10"SPR r 146/78 REPAIR PLAN ``` msp ports LOCATED AT: PAR .. r CEL ID. 122/92 \ #130 130 SETH- GOODSPEED'S WAY ; • AREA=17,922t S.F. /. •� - - TOF=61.68 .. �G� /� �: 3 - OSTERVILLE, ,MA. PREPARED FOR " 60.3 -JUDITH L.-- FLIGG & BARBARA J. LOUGHLIN �``� I � ,• _ ,,, SEPTEMBER 16, 2012 REVISED: 10/10/12 kv �% t n D N M. , <%, / _ _ 6� r " moo., 1140 r f P5\ P SCALE: 1"=20'. GI CEP D 4'1/ oITAR "\kk GENERAL NOTES: I. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY I.E. LOCAL 7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. BOARD OF HEALTH AND THE DESIGN ENGINEER. ' �j 8.ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE v /C�� LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: 9• IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY MEYER &�O SONS . INC. - 310 CMR 15.405 (1) (B): I THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO BEGINNING r // 1) A 0.27 Ff. VARIANCE FROM 310CMR15.221(7) TO ALLOW�LEACHING CONSTRUCTION. `, 9�1 TO BE 3.27 FT (MAX) BELOW GRADE VS REQ'D 3 FT. II 10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE V. P.O. •0• BOX ` PARCEL ID: (H20/VENT PROVIDED) 6 11. 48 HOUR NOTICE FOR'ENGINEER CERTIFICATION v 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR 12• THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY EAST SANDWICH, M A. 02537 122/91 TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY DESIGN ENGINEER.. ( 13. NO PRIVATE WELLS WITHIN 100 FT. OF-PROPOSED LEACHING ll��J 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING 14. ALL PIPING TO BE 4" SCH 40 0 1/8"/FT (UNLESS SPEC. OTHERWISE) (5 0 8)3 6 2-2 9 2 2 i- FROM THOSE SHOWN HEREON SHALL TI REPORTED TO THE DESIGN 15. THE DESIGN OF THIS SYSTEM -DOES NOT ALLOW ENGINEER BEFORE CONSTRUCTION CONTINUES. 5. ALL ELEVATIONS BASED ON ASSUMED DATUM. FOR THE USE OF A GARBAGE GRINDER F: 6. THE DESIGN ENGINEER IS.NOT RESPONSIBLE FOF� THE FAILURE OF 16.•NO.WETLANDS WITHIN 100 FT. OF PROPOSED LEACHING HEALTHrF R PROPER INSPECTIONS DURING CONSTRTRUCTIO- OF SHEET 1 OF 2 J#1473 - r NOTE`: TO•PREVENT BREAKOUT, THE PROPOSED NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS FINISH GRADE SHALL NOT BE < EL:56.93 _ FOR A DISTANCE OF 15' AROUND' THE ' " PERIMETER OF THE S.A.S. SEPTIC TANK PROPOSED D-BOX PROPOSED S.A.S. OF T.O.F. EL.=61.68 INSTALL RISERS & COVERS OVER INLET & INSTALL RISER & COVER INSTALL A 4" DIAMETER INSPECTION PORT OVER OUTLET AND SET TO 6" OF FINISH GRADE SET TO 6" OF GRADE ONE CHAMBER (MIN.) AND SET TO 3" OF F.G. 2�`� �tio - F.G. EL.=60.70f o DAR N ✓+ F.G. EL.=60.St F.G. EL: 60.2t F.G. EL: 60.20(MAX.) VENT `-' M Y R 1140 9" MIN COVER/ L = 10't 36" MAX COVER L = 45' L = 6'(MAX) INSTALL INSPECTION PORTS IN EACH ROW sj� � t ` ® S=1% (MIN.) EL. 58.50 ® S=1% (MIN.) 0 S=1% (MIN.) 4"SCH40 PVC 4."SCH40 PVC 4"SCH40 PVC SANITA?, V^ 1o"I s - 10.75" TO 14 INVERIA T r r • INV.=57.40 48" L/OUIO kNV.'= 57.15 LEVELPROPOSED _ GAS BAFFLE D BOX INV.=56.53 J2 TRENCHES OF 6 UNITS AT 5.00'/UNIT = 30.00'/ROW INV.=56.7 DB-3 (H2O� '' INV.= 56.47 SOIL ABSORPTION SYSTEM (PROFILE) EXISTING 1.000 GALLON SEPTIC TANK - • RESTORE VEGETATIVE COVER ' EXISTING SEWER OUTLET _ �'-'FILL WITH CLEAN PERC SAND - - TO ITOP OF CHAMBERS 60" NOTES: 1) CONTRACTOR SHALL VERIFY ALL EXISTING f PIPE INVERTS PRIOR TO CONSTRUCTION - F EXISTING SUITABLE . 2) D-BOX SHALL BE SET LEVEL AND TRUE TO BREAKOUT=TOP ELEV.=56.93 MATERIAL GRADE ON A MECHANICALL COMPACTED SIX k INV. ELEV.= 56.47 INCH.CRUSHED'STONE BASE, AS SPECIFIED IN BOTTOM .ELEV.= 55.60 - 310 CMR 15.221(2) 2.88' 6.00' 2.88' 3) REPLACE EXISTING 1,000 GALLON SEPTIC 5' MIN.' ABOVE BOTTOM OJF• TANK WITH- 1500 GALLON SEPTIC TANK T.P: EXCAVATION OR G.W IF FAILED, DAMAGED, OR UNDERSIZED. USE 2 TRENCHES OF 6 - 16"-ARC3616 HIGH 4 INSTALL INLET & OUTLET TEES W ZABEL (5.65' PROVIDED) CAPACITY ADS tUNITS-NO STONE ) / BOTTOM OF TEST HOLE EL.=49.9 - t f FILTER AND AS. BAFFLE AS REQUIRED G Q SEPTIC SYSTEM PROFILE �- TYPICAL SECTION - N.T.S. DESIGN CRITERIA 'SOIL LOG "1 P#: 13733 R NUMBER OF BEDROOMS: R EXIST/3 R' DESIGN NO--FLOW INCREASE •P PROPOSED O S B E 3 B DES - 2 / T S PT M R 1 2012, DATE: E E BE 2 - • , 10.75" _ - � SECTION INVERT, • SOIL TEXTURAL`CLASS: -CLASS,I .. " SOIL EVALUATOR; DARREN M. MEYER, R.S:, CSE. #1614 REVERT END CAP DESIGN PERCOLATION RATE: <2 MIN/IN y _ WITNESS': DONALD DESMARAIS, BARNSTABLE BOH " _ 0 FLOW: 22 G.P.D.G AI LO DAILY - •R H HAM •R 'H LOAD)_ -ADS A C 36 C C BE 20 I v. •Ee TP 1 � h D.Pt Elev. T P-2 Depth DESIGN FLOW: 220 G.P.D. - GARBAGE GRINDER: (NOT DESIGNED FOR GARBAGE GRINDER) • 60 20 A 0'' 60.20 A 0" MODEL ARC 36HC ' LOAMY SAND LOAMY SAND LENGTH 63" PROPOSED SEPTIC TANK: USE EXIST. 1,000 GALLON CAPACITY 10YR 3/2 70YR AN NOTE: UNIT CONFIGURATION AND AVAILABILITY SUBJECT 59.45 1 9" 59.45 9" EFFECTIVE LENGTH. 60" TO CHANGE WITHOUT NOTICE. PRODUCT DETAIL MAY LEACHING AREA REQUIRED: (220) = 297.29 S.F. _ B g DIFFER SLIGHTLY FROM ACTUAL PRODUCT APPEARANCE. SANDY LOAM 1oYR s s SANDY LOAM- SIDE WALL HEIGHT 10.75" 74 / 1 -10YR s/s OVERALL HEIGHT 16" DISTRIBUTION BOX: DB-3 (3 OUTLETS (MINIMUM)) -57.38 ; 34 57.38 34" 4640 TRUEMAN BLVD C _ C OVERALL WIDTH 34.5" PRIMARY S.A.S. MEDIUM SAND MEDIUM SAND 10:7 CF s HILLIARD, OHIO 43026 F USE 2 TRENCHES OF 6 - ADS ARC36HC UNITS WITH NO STONE 2.5Y 6/4 2.5Y 6/4 CAPACITY (80.0 GAL) ADVANCED DRAINAGE SYSTEMS. INC. t� • I r4 TRENCHES: - (GENERAL USE APPROVAL FOR 7.79 SF/LF OF CHAMBER PERC @ I PROPOSED SEPTIC ' SYSTEM/SITE PLAN (CHAMBER UNITS) 12 UNITS x 5.00 LF x 7.79 SF/LF = 467.40 SF EL. 56.20 +123 49.95 123" 130 SETH GOODSPEED'S .WAY, OSTERVILLE, MA TOTAL AREA = 467.40 SF 49.95 PERC RATE <2 MIN/IN. ("C3" HORIZON) PER SIEVE.-SAMPLE Prepared for: Fligg/Loughlin Ems DESIGN FLOW PROVIDED: 0.74GPD�SF(467.40SF) = 345.87 GPD > 220 GPD req'd- • NO GROUNDWATER OBSERVED Engineering by: Surveying by: SCALE • DRAWN DATE: j MEYER&SONS,INC. MacDougall survey NTS D.M.M. 09/1 6/1 2 • I, Darren'M. Meyer, R.S., CSE, hereby certify that 1 om currently approved by MADEP pursuant to 310 CMR 15.017 pD80X981 (508) 419-1086 to conduct soil evaluations and that the above analysis has been performed by me consistent with the CHECKED SHEET NO. requirements of 310 CMR 15.017. 1 further certify that I have EAST SANDWICH,MA 02537 q y passed the Soil�Eval. .Exam in October, 1999. g 508-362-2922 D.M.M. 2 of 2 REVISED:' 10/10/12