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0160 SETH GOODSPEED'S WAY - Health
1 60 Seth Goodspeed's Way r Os4terville P A = 122 095 T U a I Commonwealth of Massachusetts 05� Iiq Title 5 Official Inspection Form J' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 160 Seth Goodspeed Rd Property Address Singer Owner Owner's Name information is required for Osterville Ma 3-9-21 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: Ins. ector Information When filling out A P 51JT $8 forms on the computer,use Douglas A Brown only the tab key Name of Inspector to move your D.A.Brown Inc cursor-do not Company Name use the return key. P.o Box 145 Company Address Centerville Ma 02632 City/Town State Zip Code 508-420-4534- S14297 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 3-9-21 ktspecroTis 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 j I� • e Commonwealth of Massachusetts Title 5 Official Inspection.Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 Seth Goodspeed Rd Property Address Owner Osterville information is Owner's Name required for Ma_ Ma 3-9-21 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. y ❑ Observation of sewage backup.or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection.if(with approval of Board,of Health): broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): obstruction is removed ❑ Y ❑ N ❑ ND(Explain.below): ❑ distribution box is leveled or replaced, ❑ Y ❑ N ❑ ND(Explain.below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): El obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3). Further Evaluation is Required by the Board of Health: 'r ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if • the system is failing.to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/W018 1itle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts -- , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 Seth Goodspeed Rd Property Address Owner Osterville information is Owner's Name required for Ma Ma 3-9-21 every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ 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 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 f Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 160 Seth Goodspeed Rd Property Address Osterville Owner - - Information is Owner's Name required for Ma _ Ma 3-9-21 State Zip Code Date of Inspection every page. City/Town - P P C. Inspection Summary (cone.) F 4) System Failure Criteria Applicable to All Systems: (cont.) - - Yes. No ❑ ® Static liquid level in.the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow' ❑ Z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a,surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia.nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. The system fails. I have determined that one or more of the above failure El ® criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board_ of Health to determine_ what will be necessary to correct the failure. 5) Large Systems; To be considered a large system the system must'serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the . questions in Section CA. # Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -� 160 Seth Goodspeed Rd Property Address Owner Osterville information is Owner's Name required for Ma Ma 3-9-21 every page. Cityrrown 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? ® ❑ 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: ID ❑ 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 16 Commonwealth of Massachusetts Title 5 Official ..Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 Seth Goodspeed Rd Property Address Owner Osterville information is Owner's Name required for Ma - Ma 3-9-21 every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: ' 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 Description: ' Per as-built card this system consists of a 1000 gallon septic tank distribution.box and a 60x4x2 ft trench. Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, diwharges_to:- Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ❑ No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? '❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2019--------367 2020-----308 gpd Sump pump? ❑ Yes ❑ No 3-2021 Last date of occupancy-.' Date Date t5msp,doc-rev.7262018 Title 5 Official Inspection"Form:Subsurface Sewage Disposal System-Page 7 of 18 I .A Commonwealth of Massachusetts -. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �/� 160 Seth Goodspeed Rd - Property Address 0sterville Owner information is Owners Name required for Ma Ma 3-9-21 State Zip Code Date of Ins edtion every page. Cityfrown p P D. System Information (coat.) 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary-waste discharged to the Title 5 system? 0 Yes ❑ No Water meter readings, if available: Last date of occupancy/user -Date other(describe below): 3. Pumping Records: Source of information: 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.7261201a Title 5 Official Inspection Form-.Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 Seth Goodspeed Rd Property Address Osterville Owner information is Owners Name required for Ma Ma 3-9-21 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.)= 4. Type of System: ® Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy Shared system (yes or no)(if yes, attach previous inspection records, if any) innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach.a copy of the DEP approval. ❑ Other,(describe): Approximate age of all components,date:installed (if known)and source of information: 1998 off attached as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): ° Depth,below grade: feet Material of construction: cast iron ❑40 PVC ❑other(explain): # , Distance from private water supply well or suction line: feet t Comments(on condition of joints,venting, evidence of leakage, etc.):- f r t5insp.doo-rev.7r2512018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts x - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 160 Seth Goodsp eed Rd Property Address Owner OSterville information is owner's Name required for Ma Ma 3-9-21 every page. Ci r'rown State tY Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5 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 gallon Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 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 looked fairly clean at time of inspection. If it has not been pumped in the previous 3 yrs I recommend pumping at time of transfer and every 2-3 yrs there after for maintenance t5insp.doc•rev.7/26/2018 Title 6 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 r Commonwealth of Massachusetts : Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 160 Seth Goodspeed Rd Property Address Owner Osterville information is Owner's Name. required for Ma Ma 3-9-21 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cone:) 7. Grease Trap(locate on site plan): ,Depth below grade: Meet Material of construction: 0 concrete ❑ metal 0 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: , F Date Comments(on pumping recommendations, inlet and outlet tee orbaffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade`: Material of construction: 1. 0 concrete. 0 metal' ❑fiberglass�, • 9 El polyethylene El other(explain): E t Dimensions: Capacity: gallons Design Flow: gallons per day t51nsp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subswrtace Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �. _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 Seth Goodspeed Rd Property Address Owner Osterville information is Owner's Name required for Ma Ma 3-9-21 every page. Cityrrown 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.): Box looked typical for its age, was functioning properly, typical corossion for its age. t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subs urface Sewage Disposal System•Page 12 of 18 •r c Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 Seth Goodspeed Rd Property Address Owner Osterville information is Owner's Name required for Ma Ma = 3-9-21 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" 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. $oil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: No observation ports located. Type: . ❑ leaching pits number: ❑ leaching chambers number:. leaching galleries number: i leaching trenches number,.length:- 60x4x2 r - ❑ leaching fields. number;dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7I W018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 78 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 Seth Goodspeed Rd Property Address Owner Cisterville information is Owner's Name required for Ma Ma 3-9-21 every page. Cityrrown State Zip Code Date of Inspection D. System Information (coat.) 11. Soil Absorption System(SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): There were no observation ports on s.a.s so exact level of ponding/staining could not be determined. 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.712612M Title 5 Official,Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 r I ' Commonwealth of Massachusetts - 0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • 160 Seth Goodspeed Rd Property Address Owner Osterville information is Owner's Name required for Ma Ma. 3-9-21 every page. Cityfrown State Zip Code_ .Date of Inspection D. System Information (cant.) re 13.. Privy(locate on site plan); Materials of.construction: + 'Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of pt nding,condition.of vegetation, etc.): t5insp:doc•rev.7128I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 160 Seth Goodspeed Rd Property Address Owner Osterville - information is Owner's Name required for Ma Ma 3-9-21 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within-100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26=16 Me 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 i Commonwealth of Massachusetts. Title 5 Official Inspection Form Y Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 160 Seth Goodspeed Rd Property Address Owner Osterville information is Owner's Name required for Ma Ma 3-9-21 every page. Cityrrown State Zip Code Date of Inspection D. System Information(cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 40t+ - Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record 'If checked, date of design'plan reviewed. - . Date' ❑ 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: # I previous inspection report X r Before filing this Inspection Report,please see Report Completeness Checklist.on next page. t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of IS Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4' 160 Seth Goodspeed Rd Property Address Owner OsteNllle information is Owner's Name required for Ma Ma 3-9-21 every page. Cityrrown 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1s of 18 _ I Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION /GO Sir resod DsCe� De.a� SEWAGE N VILLAGE 1)21nsyyi*_ ASSESSOR'S MAP&LOT 02 2 09� INSTALLER'S NAME&PHONE NO. 77•o1 fg9 SEPTIC TANK CAPACITY M00 LEACHING FACILITY:(type) -(size)= 6 0 X SAX 2 NO.OF BEDROOMS '3 BUILDER OR OWNER f79wA-lzm PERMITDATE:_/D-344-9B• COMPIdANCE DATE Separation Distance Between tbe: Maximum Adjusted Groundwata Table and Bottom of L.eacbing•Facility• Fat 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 fato facility) Fret • Furnished by by . c -- Assessing As-Built Cards . Page 1 of 2 TOWN OF BARNSTABLE LOCATION 140 'S SEWAGE# v,LLAOE ST rv,l ASSESSOR'S MAP&PARCEL INSTALLER'S NAME dt PRONE NO. SEPTIC TANK CAPACITY Lip LEACHING FACII TTY(type) TreneJ- �d x y x NO.OF BEDROOMS 3 OAR CArUen PERMIT DATE: COWLL4NCE DATE: Separation Distance Between the: Max mum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply We0 and Leaching Fae ft(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaoldng Facility(lf=W wetlands exist within 300 fed of leaching facility) Feet FURNISHED HY /1SD&0M Sk I SUA rOO^ d aq al httvs://town.barn§table.ma..11RmP.nnrtmpntc%AQQ,-ecirin/Prnnarf., ininn'.. COMMON,NEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 ` OFFICIAL INSPECTION FORM=N.OT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM FORM PART A CERTIFICATION Property Address:. 160 Seth Good;�eed:Road Osterville,AI[A'02655 Owner's Name: Maureen Cai en' Owner's Address;: L. .k Date of Inspection November 2 t2t,12 ' Y l . Naive of Inspector. (Please Pi ini)(James elf For d Company Name:' JaniesMTord Mailiiig',Address:. P.'O.+I3olq X 49+ =` ' 02655-0049 Ostei i i11e;MA Telephone Number: (508) 8624400, CERTIFICATION STATEI'IENT 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 train i.ng and experieiice in the proper functioit and.maintenance of on site sewage disposal L Systems. I am a DEP approved system i�,p+uVsuant pY Section.15.340:of Title 5(310'CMR 15 000). The system: I Passes ;onditionally Passes' .. e ds Further Evaluation by'the Local Approving Authority ai Inspector's Signatui e r, Date: 1VoDeniUei 8:2012 The:system' inspector shall subm copy_ofit riS inspection report to the Approving Authority(Board of Health or. DEP)within 30 days of completing this inspE�,ion._If the.system is a shared system or has'a design flow of 10,00.0 gpd or,gi-eater;the inspector and,tte system 0wt er 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 1 1} i.tb (Pfe es u Ere: , .` a !les l Notes�alid.Comments **':!-,This t only.desct tbes;:condition's` t the time of inspection and under the conditions of:use at that time. This inspection does`not address Iioj�,the systein will perform in the future under the san e.or different conditio'l use'i` /) /7 n _ I 4C1:1 1. c[°i aLG;jC 111t�,t 1.!h . F V TitleS•Inspection Form rtttj6/15/2000r;} la k q '�s page I Page 2 of 11 ]5 ; •i OFFICIAL1INSPECTION FORM'-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,fug. , x G ` CERTIFICATION (continued) . Property Address: t. iit 160 Seth.GooAhp ed Road t aid:. Osten;ille°MA, Owner: ".1 Maureen Carvcn Date of Inspection: November 2,2612 Inspection Summary Check A;B,C,D of E/ALWAYS complete all of Section D A. System Passes ' ✓ I have not found`any information which indicates that anyof the failure criteria described in 310 CMR 15.303 or in`310 CMR 151.304 exist...Any.failure criteria not evaluated are indicated below. ' Continents: i B. Sys tem'Conditionally Passes: . One.or mote system components as,`described in the"Conditional Pass"section need to be replaced or repaired. The system,upon complet>oii'of the eplacenient or repair,as approved by the Boatd o£Health;will.pass. Answer yes,no or not dete'h iined(Y,N,ND)g iri the for the following statements. If"not determined",please explain. }NJ,)°1'l:;f The septic tank{,,metal and{over+20 years old*,or the septic tank(whether metal or.not) is structurally unsound,exhibits substantial.mfiltiation ot-exfiltration or tank failure is imminent. System will pass inspection if the existing tank isiieplaced with a comply ng 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'tlat)the tank is less tliari+20 yea"rs old is available. ND explain' 1 )'Observation]of se vage°backuptor.bleak 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- a roval of Board of Health # pp ) pipe(s) are replaced. obstruction) .removed distribution box is'leveled or replaced_ un Ks,{d - ND explain }T� Tlie system required puriipmg,t ore;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):., p .1..- - (°il a : brokengipe(s)arereplaced } obstruction is remove_d , rJ FI'd 7.11:11 i i1 c l ri]'I1','}1 - {, ,J§ Page 3 of 11 # t OFFICIAL INSPECTION FORM-NOT FOR'VOLUNTARY ASSESSMENTS'. . ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' y': PART'A .; ,CERTIFICATION (continued) G , Property Address: 160"Setlr Gbo'dsbeed Road i f Qst&vdk MA Owner: �Marneen Carvers i ... ' Date of Inspection1: Novenzber2, 2012 C. Further Evaluation isI equired by the Board of.Health.. Conditions exist w ith require further'evaivation by the Board of Health in order to determine if the system is failing to protect public..,,alth,safety or the environment System will pass unless Board of Health determines in accordance with 310 CMR 15.303 1)( )b that the (. systeni.is not furitctioning in a manner which will.prote.ct public health,,safety and the environment:. Ce'sspool'or privy is within 50-feet of a surface water.,r Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh ) } r�Y '(I i1 2." System will fad unless the Board of Health(and Public Water Supplier,if arty)determines that the system is functioning ill a InAnner that protects the public health safety and' environment:,� o A t l'; >The system has a'j(septic taiilc'and soil absorption;system,(SAS)`and the:.SAS is'wrthin 100 feet of a surface water supply or:tributary fo surface water supply. ` 1.,+.kit,].; t,,s; .r koThe systeinhas Wseptrc tai�lc and SAS and the SAS is`within a Zone`l of a public water,supply.;- f systeni'has aiseptrc tank,and,SASand the SAS is within 50 feet of a private.,water supply well. E ttJ t The system has aj.septi`Manlc and SAS and the SAS is less than.100 feet but 50.feet or more from a 1t rrvateswater�.su l well**.tMethod,used to determine distance . ' P"� tiPP.Y, ' Ott_ ?" This sys`tetn passes rf tlie�well+water analysis,.performed at a DEP certified laboratory; for colifonn liastenai!ar d+wolat lie organrcicompounds indicates that'ihe well is free 66in pollution from that facility.and the.pr6sefice of aiinnonia nitrogen and nitrate nitrogen is equal to or less:than 5 pp'in,provided that no other failure criterra'are-,triggered A copy ofthe analysis must be attached to this form. Y s Ji 3; Otfier t'u s. •a.�_rr �v"�t�, z Art rPtit¢ �L' II'�1;.a;1 x;# t;l`�� Ill�;tlJ r21i I tlt�lrl> �.,krtt'lt t' [� i S,fti;, ..` ...- .' Ti - 3 I f ct ,\ , t`ir r tf l 6e all jt�ov- P { f Page 4 of 11 ji OFFICIAL INSPECTIOV°FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t; PART A } ' 'CERTIFICATION (continued) Property Address: 160'Seth Goodsyeed Road 1. Osterville,MA,. 3 ' Owner: 'Maureen Caryei",- Date of Inspection: Noventbei-2, 21112,, , D. System Failure Criteria applicable to all systems: You must indicate either".yes"or"no",to.each of the following for all inspections: 3 Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharg 'or ponding:ofeffluent to the surface of the ground or surface waters due to an overloaded or clogged SA'S or cesspool ✓ Static liquid level in the.dlstribution box above outlet invert due to an overloaded or_clogged SAS`or 4, ; .. - cesspool r, ✓ Liquid depth in cesspool.is'less than 6"below invert or available volume is less than %z day.flow ✓ Required_pumping more than 4 times in:the last year NOT due to clogged or,obstructed pipe(s). Number of times pumped ✓ 1 SAny,po>ltionrof the SAS;cesspool or privy is below high ground water elevation. ✓ WorMnrof�cesspool'of privy is within 100 feet of a surface water supply or tributary to a_surface supply. . ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well: ✓ Any poitionof a.cesspool or-privy is within SO,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 . ;Ira!ry t 1r r s,"supply well with no acceptable water quality analysis. [This system passes if the well water analysis, perform ed!aQ9_jDEP certified laboratory,for.coliform bacteria'and volatile organic compounds, - indicatesthat�':t'li'e welhis f[e'I from�pollution from that facility and.the presence of ammonia i`, nitrogen.attd'nihtate nitr"ogen is equal to or less than 5 ppm;provided that no other failure criteria are triggered. A copy..ofUle analysis must be attached.to this form:] .'II '' 111I No '((Yes/N6)Jlie system fads."Iuhave:deteri 'ned 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 benecessary to correct the failure; P.•:,( E: Large System : 1'I , `i . h• ,l To be consider ed''a lat gelsystetii?tlie sys,eiiii=st serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate:eithei iyes'i or"no'I to each of the following: . - (The follow Ig criteria apoly(to large:systetns;,iii addition to the criteria above) oa t 1,1.,;}:�u il,n(i: Yes" No /ti°iv 7tit 1l of(r':r r l; r 'the,systernfis.0ithm 4.©01feet.of a surface drinking water supply the system Hs,within 200 feet of a tributary to a surface drinking water supply the;system is 1'ocated in,a;t;itrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a snapped Zonellr *f a public%water',supplY well If you have answered yes' toy,aiiy question t i Section the system is considered a significant threat,or answered "yes"in Section D,above;tthe large;'system has'failed. The owner or operator of airy large system considered a significant threat underlSection E;,br failed+under,Section D shall upgrade the system in accordance with 310 CMR 15.304. The systeri owner should eotitactIthe appropriate regioiral office of the Department. 4 •'•��-- � t .C::l�C ' l 1't sl tt:`;I i) � '�� :. F 1.. C;(� t ly. i 1 t i t if Page 5 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE�SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4 F w PART B CHECKLIST Property Address: 160 Setla Goodsveed Road Osterville,MA Owner:` 'Cloven Date of.Inspection: ° Novei�abe��2;"2012 ' Check if the following have been.done:• You,must.indicate yes..'or..io".as to each of the following. Yes No ° — Pumping information was provided by'the owner,occupant,,or.Board of Health Were any,of the system components pumped out-in the previous two weeks? Has the system received normal flows in`the previous.two week period?: I"L '. . Have large volulnea of wafer been introduced to the system recently or as part of this'ini pection:? I , Wejie as�jbuilt,plans iaf lie System obtained and examined? (If they were not available note as N/A)_ ✓. Was the facility of dwelling inspected for signs of sewage backup.? Was the site inspected for signs of breakout? i'✓ ++ F i li f:Were all sy_steiii`compotiems,.excluding-the.SAS,located on site? "✓ti +': Were the.septic fank matrholes�uticovered,op`ened,'and the interior of the tank�iiispected for the condition of thelbaffles3or'tees,mateiialbf construct oar,dimensions,depth" of liquid;depth.:of sludge and depth ofscum? #sj ✓: '. .t i�r,.° I i;c;sWas'the fac hty ovine `(and occupants if different from owner)provided with information on the proper, maintenance of subsurface sewage disposal systems {- W The size and location of the Soil Absorption'SyOem(SAS)on the site has•been determined based on: s LL,I .t,+ �,v Yes`. No aistm, ii,ormatton ;For example,a plan at the Board of Health. ✓. {: De termuied•m'tlie field,(if any.of the failure.criteria"related to Part C is.at issue appioxiniation of distance. is unacceptable) [3"10 CMR 15.302(3)(b)].`, __ y�� t •:I � �I tat w �i 1��; it��: Alta rs t 1 7 3 t r ''it , ktl.. 7�'iC r� G, .Ft7'ti{Ci $rlirrl U�,�- - 1ti Page 6 of 11 t OFFICIAL INSPECTIC\ FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE, SEWAGE DISPOSAL SYSTEM INSPECTION FORM P tt PART C *'SYSTEM'INFORMATION ;. Property Address: 160 Seth:Goodspeed Road Osten)ille.MA+ Owner: Matnreen Carves Date of Inspection: November 2, 2012 a r FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 dNumber of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (fir.example' 1'10 gpd x#.of bedrooms). 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no);_, Yes . Is laundry on a separate•sewage'systern(yes of no) N/a •:: [if yes separate inspection required] Laundry system inspected(yes or no): rio Seasonal use(yes or no): no Water meter readings,if available(last 2 yea-s usage(gpd)): Unavailable Sump Pum (yes or no): No , L'ast`.d'at6of occupancy: Currenth COMMERCIf11/I!NDUS;T$IAL',',it t.. �I Type of establishmefttli! Design flow(based on 310 QMR 15 203)'• ` gpd Basis of design flow(seats/persons/sq/ft etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes of .-:o) Non,-,sanitary,wa'ste discharged toy th Title_5:yystem(yes or no): Water meter readings, if available r .t.. :,'.1 . tLast date of occupancy/use;:., 1a,9•-, a!1 3�7 G:,i},_+.ire h.iM 1+ +9-[ -` 1 - OTHER(describe):. - GENERAL INFORMATION Puinping'Records i 4 _a Source.ofiiiformation i,"l.aptrntyed:in:2010-pei owner Was••system'Ipufiiped as,pe taof theiinspeetion;(yes or no): Yes If yesltvo�lunie pumped :,t ,v,igall6nsi= How was quantity pumped determined? Reasoii;•for'pumpiiig.. Muiiel2aiice r,ti:• �14"ct 1. nor. JS �i ��+ LL. l'i,Septic.tank disc iliutioii box,-soil ab.soiption system n':`t ia:.. Single.cesspool Overflow cesspool - 4'i:-diil t•:iyrlvy �.P.,;I`��I91`� :lZiAL � ,,Shared..system(yes or no)• (ff.yes�aItach previous inspection records,if any) i. :i I?Ifinovative(Alferlatfve,tec imology: _Sttach a copy of the�current operation and maintenance contract(to be obtained.frofn system osvnei) t t .t:, tt' t rTight Tank ryc c t._. Attach_a copy of tlie'DEP approval Approximate,age'of all+components,date installed(if known)and source of.informatfon:on:, Ddte'of iiistallcitioii.lII4/A8 per as-bcnit ca!d Were.sewage odors detected when arriving at the site(yes or no)- :No • 1 �is 61, i r Page 7 of 1 I s OFFICIAL INSPECTION-FORM.-NOT FOR VOLUNTARY ASSESSMENTS' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i w PART C ' SYSTEM.INFORMATION (continued) Property Address: 160'Seth Goodspeed Road -Os ter7,ille.:MA' Owner: Maureen Car-ven , Date of Inspection: Noubnber 2 2012 BUILDING SEWER(locate on site plan) , Depth below grade Materials of construction: `_cast iron !40 PVC other(explain). Distance,from private:water supply well orsuction line: Coinnients(on condition of joints;venting,.evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site pla i Depth below giade`•I� L'6'' :y ga.h :'1 g f t t,,.[,', Material of construction i>✓ concrete li x 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) t' Dimensions: 1500 gal. Sludge dep"tll J (n,s: 2 rr Distance from top of sludge,to bottom of'o'utlet tee or baffle: 30" Scunvthickness: 1" Distance€.fromttop iqf scum to_t'op(of ou baffle::tlet tee or. 6" Distance from bottom of scum to bottom of outlet`tee or baffle:' 10" How were dimensions determined: MeasttrinQ'stiek Coffihlents'(6'ni' uiiipuig'reconinielidatioiis,;inlet and outlet tee or baffle condition;structural integrity;liquid levels ..as related to outlet invert,evidence`ofleakagc;etc:).' Tlie btiffles were vreserit:....The'lipuidlevel i'as even with the outlet invert There did not'app6r to be anv signs ofleakake 'The inlet cover'isr iriden the.edoe ofthe uo clzt °F. q•Iz�#:, . ."iEi lll ::ft Tic;: t ,}f..':'ltr,li'fil;' to'T(,lt ' - GREASE TRAP:% iNone'�: (locate':ori site,plan), s Depth below.glade: Material of construction: _concrete = metal _fiber glass;:=polyethylene _other, -, Dimensions:- - Scumitlllckriess Distance fromitop;:of scurf to top of outletfee orbaffle: Distanbe.(frointbottomrof_scu>n to_bottom.of outlettee or baffle: 1)ate'ofilastpuniping .` I . .. _u.iti!:I ra.1 " Copunelits:(on pumping recommendations inlet and outlet tee.or'baffle condition,structural integrity,liquid levels a lrelatedito'out1.let_,tnvert,.eyrdence.of,leakage,etc): Jj,.t9 1i li',- '.it] t�'.,,,Orj .. 10 01 C Jjr2.: f!� i <; 7 IV!!''(.;.�.( ti'rti;3 hL Ilikl til:i?i1.11 i ._f.;:1 t tt�ij}(1t31S1 :i� t ..i.l:yr 1.. 1ti,11'tll( L lzt ftIr ll 1 Id��,ir IS,',�,rc l let r i � t RC 'ia:- ltl 'G tr i�7'i,: tt..H. , w tli�.1 111i l.. l +tt�l; �lt.,L .il r >b•lt . t—' is U, . rsf;1 ti r 0 f 7 1 i Pae',8.'f-lag t OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL°'SYSTEM`INSPECTION FORM PART C SYSTEM INFORMATION (continued). I Property Address: ' j 60 Seik Good4ed Road Ostei�vrlle,MA• Owner Macireen Cariten Date of Inspectioii: Norenrber 2.-2012 TIGHT or HOLDING TANK: None_(tardc must be pumped at�trme of inspection) (locate oil site plan) ti Depth below grade: g Material of construction:._concrete _metal' fiberglass _polyethylene =other(6xolain Dimensions Capacity: a.gallons E Design Flow. gallons/day° ` . Alarm present(yes'or no); Alarm level: �` Alarm in working or der f(yes or no). Date of last Pumping: ,y Conimefits(condition of alarm and float switches,;:etc.): I r, a"! DISTRIBUTION .BOX:`' ✓ (if pres'drit must be opened)(locate on site plait)' D'eptli'of liqui evel above outlet.nveit. EE:Eve)� ' Coimnerits(note if box is level ai d'drs'trib.ution to,outlets equal arty evidence of solids cariyover,'anyyeviderice_of 1'eakage:into ror out of box, Tlie D�bos i vas�rioi vial. The 6over`auas�2-S-".�be'loiv-Qrade PUMP CHAMBER: '`None (locate of 'kt'e plan) . Puinpsnulworlarig orders(yes "Alarns in,_workingeorder(yes or_rio) Cbmrffents'(note cQn itroii of pump charilber, condition of pumps and appurtenances,etc.):, '. t b ot 2 1 t,'�I (��)f)E'�.� 1 � k �1 l I e� l � ��'�( ��.( •�}:Ih r If�I�'.A_ J Y.£ - - - - 8 DWI Iq rf I A;E? Page 9 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM E 'PART C SYSTEM.INFORMATION (continued) Property Address 160 Seth Goodsve'ed Road ' Osterville.MA Owner: Mau Can)en Ca ,eii Date of Inspection: November 2, 201 SOIL ABSORPTION SYSTEM(SAS);' ✓ > (locate on site, excavation not required) 5 �1 - If SAS not located explain why: Type leaching pits,Humber . leaching chambers,number t'' '.'�• "leaching galleries,number ✓ leaching trenches;number, length: 60'x4'x2'ver as built ` r: ,[ Y. leachingk$elds,nunibef,aftlensions - ovelflow cmDool;rnlimbelr�r,.(,z t Irmovative/alternative,system Type/natne of technology Colnnients(note condition of soil,signs o f.hydraulic failure,level of ponding,damp soil condition of vegetation,.etc.): There did not appear to be anti signs of fail i e`frorii leach held. A came-•.ivas.used for the inspection CESSPOOLS: Norse " (cesspo(illinustlie:pumped as part of inspection) (locate on•site plan) Nuinber!andfeoilfiguratioli:. fir, i c`.n J ',.,'_ ,._. Depth:-top of liquid to inlet invert: Dd^ofsohdsllayel Dimensions of cesspool`. Materials.of consti-uctioi:• `E Indication:.of groundwater inflow(yes Conln�ents_„(note condition;of soil;,signs of hydraulic failure,level.of poiiding,condition of vegetation,etc.):. PRIVY h:1Vone locate,on site lan E.:iCc�1i e�fr4illFti. kEf l.:il,b `. • Materialg'of constmctron. D1met1SloriS.�7 r., fir lr�. rig:{r�{,r` �'siio{ .f. t Depth of solids :r Comments.(note cond,ition:ofsoil 'signs of hydraulic failure,level of ponding,condition of vegetation;_etc.): r�u {Ir 'p6 'f, i„ .�7'rll'tt •.Ia , I �t I:`;I:t�.,i„I�,I '<,+.,�}k'1 d (uii'�' rt,r" '• `.2 v,J,9)3 lli:l fh T"41 J:H} .9 . ��},'�C.i.t i� i5. .�tt.ti.�' it r,.ae' _ _—_.• _ - .. - - M. K� "„!f1<1Ct, i'1•-� �1 � .�'I° tr' t} Page-1.0 of_11.. - OFFICIAL:INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS j SUBSURFACE,SEV�AGE DISPOSAL SYSTEM INSPECTION:FORM .PART C . SYSTEM INFORMATION (continued) Property Address: '160 Seth Good,peed Aoad Osterville,MA Owner; Maureen Carvc>n .. Date of Inspection: Novetnbei•2,2Q12 ' SKETCH OF SEWAGE DISPOSAL SYSTEM, Provide a.sketch of the sewage disposal system including ties to at least two perinanent referetice landmarks or benclunarks. Locate:all,wells within 100 feet. Locate where public water supply enters the building. . a ';t rf try, i k.Ir X - }�',b I.�. PN f•�14'•it4 t( 1�?!. - F---"ry t r ! r r �+ r --- -----—--.— '------ -----— ---�- .__ - • - (it=l'f[ SVA (ppM10 �9 �1 t Page 11 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION (continued) Property Address; 160 Seth Goodspeed Road ' Oster ville,MA Owners Maureen Car ven Date of Inspection: November 2, 2:012 SITE EXAM, Slope. Surface'water Check cellar Shallow wells , Estimated'depth to ground water 40+/- ';'feet I 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) vl Checked wth!local!$oard'oKH'ealth'explain` -TovoQravhic and water contours niays Checked with localh excavator s,uistallers F(attach documentation) Accessed USGS:database-explain You must describe how you established the high ground water'elevation: ,:rill ll a.,:;:: � r 111;.: 'IV�'fU(, 7. �, .,_ �'•. `.. . , ' : '`- UsinQ Barizstcrble.topoerayluc and -eater contoiti s nlays; the nrays were showing appr oxinlatehr 40 +/-to Qrotnid water at this site. t ILI I r I' '';t 111�:Cd1 S. •.!tl t I i ,al'i 11 t t p. ii u.�1( l-! a t i .. .This i-epo.rt has bee11 plepat, Oltl)%fol'the.septic SyStenl aI1d,C,0117p011e111S described 17e1'2[e. TIICS septic sySle171 jras been. tivspec[ed,nrrd passed-as of thetdate of inspection. Th,&report is not a vvarrniiry orgrrarantee'that the systeeIL W"I _f rliCtl,OrLpl'Ol7e/ i17 the firtur e reThereehave been`no warranties'or•glm-dntees,-either expressed, written or implied, - - relatrllg to the septic systein tthelinspeviorlr this report and/or.any components of the septic systemwhich have not _ , t been locnted and respected dlt l ,wl ' i( r Ii..; t �Kcll llg7D{�1 fit{l •C't-0 . ; 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP PARCEL • - q �'n L0-171 . TITLE 5 - � OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: /6 0 seh 6:oOdS�Pcl lea, OS ,vi l ie , At Owner's Name:Owner's Address: C/o ffiaud erl &)2 veA 3 2 a LQ kes4 O re b R)N 2 Date of Inspection: Q /` M ► II S , M A- ©2G� g 3I2oIoct Name of Inspector: (please print) Joseph M. Martins RECEIVED Company Name: Accu Sepcheck Mailing Address: 17 Northside Dr., S.Dennis,MA 02660 MAR 3 0 2004 Telephone Number: 508-385-5891 TOWN OF BARNSTABLE HEALTH DEPT. 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 ection 15.340 of Title 5(310 CMR 15.000). The system: Passes \ Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Li� Date: 3, L 3 _Q The system inspector shall su mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: SEAnC 7-4 1 � S '7' h'711 y V A�P So room a i .So i0 fVbe,- sularvV-t' A; Cc -f- I-q ]-C+ 2n A ©"-P 71i-A) K w )n T W- ****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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 160 Seth Goodspeed Road, Osterville, MA Owner: Marr Date of inspection: 3/20/2004 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 break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced" obstruction is removed ND explain: Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 160 Seth Goodspeed Road, Osterville, MA Marr Owner: 3/20/2004 Date of Inspection: 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: ova �tJ -o Xi M o S'P T7 L �4 To L'nfri9om Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 160 Seth Goodspeed Road, Osterville, MA Marr Owner: 3/20/2004 Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ,- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or ,eesspool `��iquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓yAny 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 forma (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 Systems: To be considered a large system the system must serve a facil' with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the follo ' g: (The following criteria apply to large systems in additio o the criteria above) yes no the system is within 400 feet of a s ce drinking water supply the system is within 200 feet a tributary to a surface drinking water supply the system is located ' a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a publi ater supply well If you have answere yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Sectio 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. -Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 160 Seth Goodspeed Road, Osterville, MA Owner: Man Date of Inspection: 3/20/2004 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant, or Board of Health ✓Were any of the system components pumped out in the previous two weeks V"'_ 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)] i 'Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 160 Seth Goodspeed Road, Osterville, MA Owner: Marr Date of Inspection: 3/20/2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CM 15.203 15.203 (for example: 110 gpd x#of bedrooms): 3 3 v Number of current residents: (l Does residence have a garbage grinder(yes or no): N L) Is laundry on a separate sewage system(yes or no):N0 [if yes separate inspection required] Laundry system inspected(yes or no):�,¢ 2003 Seasonal use: (yes or no): Al 0 i Water meter readings,if available(last 2 years usage(gpd)): 1;)_OOv�_ T //9' 00 d Sump pump(yes or no):_ Last date of occupancy: COMMERCIALANDUSTRIAL J Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):Industrial waste holding tan _ent(yes or no):_ Non-sanitary waste arged to the Title 5 system(yes or no):_ Water met rags, if available: Las e of occupancy/use: OTHER(describe): GENERAL INFO TION Pumping Records �� �� W PV Source of information: a1 i/ d Q v Z Was system pumped as part of the inspection(yes or no .)© If yes, volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM V 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 i formatii: C lVe Were sewage odors detected when arriving at the site(yes or no): A/19 Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Seth Goodspeed Road, Osterville, MA Owner: Marr Date of Inspection: 3/20/2004 BUILDING SEWER(locate on site plan) Depth below grade: v Materials of construction._cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: S/o' Comments(on condition of joints,venting,evidence of leakage,etc.): K SEPTIC TANK:_(locate on site plan) Depth below grade: 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) / /� t • C r/� 5—� 7 II Dimensions: �( � (j Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: j O Scum thickness: Q t{ Oil Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto of outlet tee or baffle: `i 1 How were dimensions determined: L L,645 P C%��� C- Comments(on pumping recommends ions, inlet and outlet tee or baf1re condition, structural integrity, liquid levels as r ed to outlet invert,evidenc of leakage,etc.): f A �t e ��r-,h� � c�/z .'� S c) �-\ v. A,- G e Fo A 5 L.JV �11P CLjS t jt -e 2 ' ttil i P- S rlv/I .'0V P/Z GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethyl _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or b Distance from bottom of scum to bottom of o t tee or baffle: Date of last pumping: Comments(on pumping recomme Lions, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): .r Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Seth Goodspeed Road, Osterville,MA Owner: Marr Date of Inspection: 3/20/2004 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete me fiberglass_polyethylene other(explain): Dimensions: Capacity: llons Design Flow: gallons/day Alarm pp! (yes or no): Al vel: Alarm in working order(yes or no): Da a of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) _ Depth of liquid level above outlet invert: +T 11vvese Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,an j evidence of leakage into or out of box etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,con ' of pumps and appurtenances,etc.): Page 9 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 160 Seth Goodspeed Road, Osterville,MA Date of Inspection: Marr 3/20/2004 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/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): . -T"Re✓�cti �4/®T xpos� o �'d�n o aiwr2e= X. 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) 1 Materials of construction: Dimensions: Depth of solids: Comments(note conditillf soil,signs of hydraulic failure,level ofponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 160 Seth Goodspeed Road, Osterville, MA Owner: Marr Date of Inspection: 3/20/2004 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. w L-� 3 s J Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 160 Seth Goodspeed Road, Osterville, MA Date of Inspection: Marr SITE EXAM 3/20/2004 Slope Surface water Check cellar Shallow wells Estimated depth to ground water 28 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: 3 . Gr—ov4W'rkV c&1'17�vr c Vjz � 1 5 s� zz_ l 7- f 1 o s-A 3 9,d,) i n Z /C lv�a7lv7 t F d f4 ` $ t E-F rEuDSt7 r � 141 EDP..�M t rJ �.SG ROO rt q ` 12 r�ITZH E-A 14` IFA141LY P?04M �,cJct�(G 2oart Existing Floorplan Is-r V� oaf Option 2 Carven Residence 8=T BATH 3EU 2aDM Zz' `g l-V EYI-S-riKY�; Tj-cvP-PLAi--3 ZQ-D ENAg = .. �� .�£ % h 3 3 k y 8 L5 t ..-. '� - b j(l O �� I 2 < I. 4 .may ; V } «J: `. 4 ... 1"• 6' w 3'X3` SHOW f .. M "' RE�OCAT E o FIXTURES ,.,�, PQCKES no !:EXISTING 'aa BY 01NNER '{ Zf :9ff dOOR`V +'� UVINDOW M 34" D� 18" $I ^ OR 1Nj GHT NEW . DE ... 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Ca even Residence 1 " '=/off11 i y 1 , Co POCKET DOOR TO BATHROOM 4 F Ii f(( ?V 5 WD. BASEBOARD AND TRIM TO MATCH EXISTING f F zw D BASEBOARD AND TRIM - � ��_ �_ Carven Residence TO MATCH EXISTING 1i4 -1 0f. ARV - Abr))TION TLO PLAN, „ - - -- - aa' t'r01�J0 5�� ��Id�i�►� n O� 3G' TOWN OF BARNSTABLE LOCATION f GO SEWAGE# VILLAGE 03rt rv% ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY (CM LEACHING FACILITY: (type) 77tn C�, (size) (00 x y X NO.OF BEDROOMS 3 OWNER C/\(Ue^ 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 S P t C. �Oil 7 Fo r� l ,Tun rooms rl � 9 -7 f � No. ! '.� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: h Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppliCotion for Miopaal *pe;tem Con!5truction permit Application for a Permit to Construct(Z-f Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.10 Fe r4 /Z-,/= Owner's Name,Address and�'el.No. y2 (>stzrVi 11-e J�^144C_s L Youx Assessor's Map/Parcelf Y,Z 0-7S. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. J65,ep, 0, Al cl-4101 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 5,'Is114Z Nature of Repairs or Alterations(Answer when applicable) GOXlf:C � Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed �! �- Date_%D Y4-9E Applicatlon Approved by Date lFd-Ja-9d" Application Disapproved for the following reasons ~ Permit No. 9,.fr. Date Issued /6-3 0-9 No. ' ' x�`� Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Migogar *patent Construction Permit. Application for a Permit to Construct(/JrRepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No�G�- Owner's Name,Address and el.No. y2. y s70 OsnerV,%/� 1=r�ahc�s L��/ouX Assessor's Map/Parcel /(, r O = , Installer's Name,Address,and Tel.No. O 3 4/9 Designer's Name,Address and Tel.No. 145,�Ph Q-e— /30rr,OyS 6,4 ow--- fi, /1G/ �/li f S �/9h9tr _. r✓ Type of Building: Dwelling No.of Bedrooms Lot,Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title �,s, Size of Septic Tank Type of S.A& Description of Soil 1 Nature of Repairs or Alterations(Answer when applicable).Zvi roll Z_15,W6,41 GDXyX .2 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system ' in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by.this Board of Health. Signed Lf Date Application Approved by Date —10—9 001" Application Disapproved for the following reasons ' tf Permit No. ��" 6 Date Issued /,0-3 0 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS n (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed (4.}Repaired ( )Upgraded( ) } Abandoned( )by 5 -c r OS at G o ,S 2e FP i11 as been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated f Installer ✓aseP,1 Q,_ &rro.P Designer ✓ 9,0,�,"OS The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date — 1 ti Inspector \ N(,. ?e—!"J -----•-----------------------'-Fee b y 7 � THE COMMONWEALTH OF MASSACHUSETTS o�2 PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwigool *pgtem Construction Permit Permission is hereby granted to Construct(4-)-Repair( )Upgrade( )Abandon( ) System located at /G 0 J',eT7., 0.5IxeV///t and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of th' pe it. Date: /G 0—, Approved b p,�-. C ` � X2 .,,r • • 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only: CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, asz ti -�_ # ___,hereby certify that the application for disposal works construction permit signed by me dated /D--SD— rX ,concerning the property located at /0 S,�r4 G�� SPA{� �� D.s2-t y✓ 15 meets all of the following criteria.:. -There are no wetlands located within 100 feet of the proposed leaching facility /There are no private wells within 150 feet of the proposed septic system ��_n�ere is no increase in flow and/or change in use proposed v There no variiancm requested or.needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will n9l be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete ithe following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) ,T B)Observed Groundwater Table Elevation(according to Health Division well map) 8_ SIGNED: DATE: Ia— LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER Attach a sketch pllan.of the proposed system.Also If the licensed installer posesses Ni certified lot plan, this plan should be submitted]. q:health folder:cent gx16 rl�y �oov G� �r�vraLi .� l y c.0 c.0 co J • O TOWN OF BARNSTABLE LOCATION 16,9 o oo/ S'�F_/ �D SEWAGE # VILLAGE.-- 01ne- 'Vil11i t ASSESSOR'S MAP & LOT 02 2 09S' INSTALLER'S NAME&PHONE NO. ci77'0-3 Y9 c/BS e, Z'i a SEPTIC TANK CAPACITY 16,90 LEACHING FACILITY: (type) �ff� (size) 6 0 A �,X 2 NO.OF BEDROOMS 3 ' BUILDER OR OWNER—� ridh �901 d,E PERMITDATE: /D 0- 4S t COMPLIANCE DATE: //- y-9 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) _ Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet,of�leaching facility) Feet Furnished by -iia, T C .� 1L TO OF B ST E LOCATIONyy"// tj) SEWAGE # VII,tAGE - ®C> ASSESSOR'S MAP&LO INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY t .► LEACHING FACILrN: (ty ) �J` �� (size) '00 NO.OF BEDROOMS BUILDER OR OWNER LQJ300Y PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site,or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I I � AA �' 00 LOFCATION EWA p E PER IT N-0. � � � VILLAGE INSTA LLER'S AVE & ADDRESS B UI-LDER OR Ow ER f Q DATE PERMIT ISSUED ��� T 7� _ DATE COMPLIANCE ISSUED �� �� „ 'v 1'T �t1 �. V No......... � �� F��..l.! ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL `H - ----OF........ .0:;; , cLI pphratiun -fur Biupuuttl Turku T_ nutrnrtiun rruiit `09 Application is hereby'made for a Permit to Construct" ) or Repair ( ) an Individual Sewage Disposal Syst s cation ess o or Lot No. ' b. ...............•.... ............................`..-•-- Owner ddress Installer Address Type of Building Size Lot.., .6�,A..... _......Sq. feet Dwelling—No. of Bedrooms------ ------________________•___________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a Other fixtures -•------- ---- ------•------ - W Design Flow____._____. :.527_,�7_____________________�llons per person per day. Total daily flow._......._...: _.. ...._.-...-...gallons: WSeptic Tank—Liquid capacit/ht'.V gallons Length---------------- Width-------.-------- Diameter---------------- Depth...______._.... x Disposal Trench—No. .................... Wi th__......_._ tal Length___-----_-- 111eacl leaching area trea__.- G' ;_sq. ft. Seepage Pit No._ .. __-_ ______ d3' w ' - g< 3._.__1�sc. ft. Z Other Distribution box ( Dosing tank aPercolation Test Results Performed by-------------- ........................................................... Date--------------------------------------- ,� Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water...-._-.--.___-_-___- 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................. . Depth to ground water__._.-_.___.___-____---- Prr-----------" ... �°� Description Soil C .............• fc .ramf - - - - W ----------- ------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------ U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ f Agreement: 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 b th board o health. P P Y gne = ma's. ......... ---------- .. f�� �---" Date Application Approved By------- -, ---- ...... ----------- ..:_.1 .-...a 7------ Date Application Disapproved for the following reasons--------------------------------------------------------------------------- ------------------------------------- Date PermitNo......................................................... Issued---------------------- ................................. Date No.-••••-••=-...--.2:.(! Fes$.. . ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA' 4- �- - OF. Appl ration -for Uhipwittl Workii Toustrurtion Vrruift Application is.:hereby'made for a Permit to Construct (_"'�or epair ( ) an Individual Sewage Disposal System at:' ,y = --------•-------------•------•-••---------------------._.....--•-•... Location-Address ` �/j�' J -or Lot No. r Owner . � Address a /�/_/ /.-�i1 �✓2'C/L�------------------•-•------- i Installer Address d Type of Building Size Lot... '__= .. ....Sq. feet U Dwelling—No. of Bedrooms-"---__, ?_-___-_-•______________________Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building ............................ No. of persons.--------------------------- Showers ( ) — Cafeteria ( ) P4 Other fixtures _.. W Design Flow........... �:__0......................gallons per person per day. Total daily flow...............�-��_..0_.---U..............gallons. P4 Septic Tank—Liquid capacity`! Ions Length---------------- Width...............: Diameter----------...... Depth_".__--_._.... xDisposal Trench—No -------------------- Width ............. Total Length............... . Total leaching area_.---.__-_----____sq. ft. Seepage Pit No.. 5.-'. : '`_ Dia'rneteer.. :<_ ------Dep f'below,inlet =" . Total leaching area... .d_ sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 614Z / � r— W Percolation Test Results Performed by.......................................................................... Date---------------------------------------- W Test Pit No. 1__.______-_-•--_minutes per inch Depth of "Pest Pit.................... Depth to ground water-----------------....... (XI Test Pit No. 2................minutes per inch Depth of Test Pit: "--"._____---___- Depth to ground water-...._.._-------------- Ix t of. Soil------------ � ' .�_V_r. ..._ 6a 'f� -------------------------------- Description V �2_f"_ S j-'- f �* •- ------------"---•------- -- W U Nature of Repairs or Alterations—Answer when applicable-------------._.-------------------------------------------------------------................... -. Agreement: ; The undersigned, agrees to install "the aforedescribed Individual Sewage Disposal`System in accordance with the provisions of Article XI of.the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the.board of health. ned .............................. ------- ...... --- a Date Application Approved B ,.. e-'.--7--7---- �.. .. Date Application Disapproved for,the following reasons:................ -------------------------... ................................................................. ................•--•-----•-------------•-----•--•-------"---"•••.."--•••---------•-••-••-•-••---------•••........_..•-----•-----•-•--•--•-----------•---------. ----------------------------------------- Date Permit No................... = =---='•••=- = . Issued................••---- ------- -•• •--•--•-••..... t. Date THE COMMONWEALTH OF MASSACHUSETTS �` • BOARD OF HEALTH I1+'�'�� OF. n. ..� lam?+ :. Trrtifiratr of TTVM;1ha1trr THIS IS TO CERTIFY, That tthe Individual Sewage Disposal System constructed (�)�or R` epaired ( ) bY----•----... . f Installer* at....... = t' ` f ' *'3�r,K_ . .._.. /f +` r --- has been installed in accordance with the provisions of A& XI of,,,The State Sanitary Coe as�le�crtl�ed in the d.application for Disposal Works Construction Permit No.A& XI date ..__>7 �f 6 .._.....---------7........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL rFUNCTION SATISFACTORY DATE.........wr•� 14 a °� F Inspector =� - � ' ------------------ � -----•-••--f�. �--- THE COMMONWEALTH OF MASSACHUSETTS 7 _ _ BOARD OF HEALTH �2' No....... . ..... '�"_.. FEE �i��rr�ttl �rk� ��t��trtxrt �i� rrutit Permission is hereby granted-__-__-.�lJ. --''tom to Construct (,-) or Repair ( ) an Individual Sewage Disposal System �_� atNo.. --•--------n...--------------------------------------r...........------..... �--- ---" Street 1-4 as shown on the application for Disposal Works Construction Pe No---- t. _14-t-r. - •- +� Board of ealth DATE.---•--•------=-------------------------------------------------------- FORM 1255 H0813S & WARREN. INC.. PUBLISHERS TMl p !!� FOUAD. MAN �„ r,Y, a o � 0 ,: tip,/ co n O I,00c GA, (J 1�fsl►�G/4 L�t{ — 0 0 r W l :.� 3 C.EQTIFIETD PLo'T" PL._.Av�j LOCAT1o" pSTERV 1 30FT ttN-r b/1 7-/77 cmzmF-( TMAT' T14r-- FoUNDAYtaPs '5"a- JQ Pt-AQ EsZ E t�f~1 Gout PLI�lS W 1 TN TWG: -S i VE.L.t►. 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