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HomeMy WebLinkAbout0048 SHARON CIRCLE - Health ��..4 48 SHARON CIRCLE Osterville, MA A= � � —�s e t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments I t } 48 Sharon Circle t Property Address Lillian Maselli - Owner Owner's Name information is required for every Osterville MA 02655 9-5. .1; page. Cityrrown 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:when filling out forms A. General Information on the computer, �011 SH OF lyq h�iii use only the tab ���� .•• .S �i� 1. Inspector: �E►; key to move your a ��. •S. cursor-do not .Sears �r JAMES James D use the return ��' key. Name of Inspector c� � *: Capewide Enterprises —Q Company Name ff'l T I F .tea 153 Commercial Street �� �r, •s SPFt�����ta Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification 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 ❑ Condltionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-5-17 spector'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 should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform tin the future under the same or different conditions of use. t5ins.doc•ref.SI1S Ttle 5 Official Inspection Form:Subwrfaos SM40 Disposal Syslem•Page t of 17 g£ a6ed xed dH ZV ZZ L l,0Z 90 d@S j i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name information is required for every Osterville MA 02655 9-5-16 page. Cityfrown state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E f always complete all of Section D A) System Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CM 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal. Tank D Box and pit B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The sepfic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15ine.dod•rev.W15 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 2 of 17 96 abed xe� dH £bZZ L 1,02 g0 daS Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form• Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name information is required for every Osterville MA 02655 9-5-16 page. Cityfrown State Zip Code Date of Inspection B. Certification (cost.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. BI System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box.System will pass inspection If(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a mannerwhich 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 l5ins.doc•rev.6/16 TiUe 5 Official Inspection Form:Subsrfsce sews a ois� posel System•Page 3 of 17 L£ a6ed xeJ dH £t,:ZZ L 602 90 daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name Information is required for eery Osterville MA 02655 9-5-16 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, If any) determines that the system is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance. This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all Inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in NEOW is less than 6" below invert or available volume is less than %day flow Rr T t5ins.doc rev.6116 Title 5 Dfttdel Inspection Form Subsurfsoe Sewage Dispose)System•Page 4 of 17 gE a6ed xed dH. bb:ZZ L 1.0Z 90 daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name information is Osterville MA 02655 9-5-16 required for every City/Town/Town page. b State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliforrn bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered `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 orfailed 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. 15ins.tloc•rep.5/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 6E a5ed xe:1. dH bb:ZZ L i3OZ 90 daS Commonwealth of Massachusetts Almo Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owners Name information is required for every Osterville MA 02655 9-6-16 per. CityfTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design); NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.2C3 (for example: 110 gpd x#of bedrooms): 330 t5ins.doe-ray.VS Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslam-Page 6 of 17 0� a6ed xej dH svzz LI,oz 90 daS Commonwealth of Massachusetts Title 5 Official- Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments S Sharon Circle Property Address Lillian Maselli Owner Owner's Name information is required for every Osterville MA 02655 9-5-16 page. Cityrrown State Zip Code• Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank D Box and pit. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected) ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2015-22,000GaIs2016-26,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: oa esent CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/Sci t., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins.tRx rev.W16 1 ille 5 official Inspection Form;Subsurface Sewage Disposal System-Page 7 of 17 �� abed xeJ dH SI?:ZZ L 60Z g0 d@S Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli :Owner Owner's Name information is required for every Osterville MA 02655 9-5-16 page. Citylrown State Zip Code Date of inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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 DE approval. ❑ Other(describe): t5ins.doc-rev.6116 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page a of 17 abed Zb Xed dH S�ZZ L 602 90 d9S Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name information is Csterville MA 02655 9-5-16 required for every page. CRY/Town state Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: NA New D Box 10-2014. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 18" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): 8 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certficate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 211 Sludge depth: t8lns.doc-rev.8118 Title 5 Official Inspection Form:Subsurface Sewage Oisposal System-Page 9 of 17 �� a5ed xed dH W22 L 60? 90 cIBS usetts Commonwealth of Massach Title 5 Official Inspection Form Subsurface Sewage Disposal System Form• Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name information is required for every Csterville MA 02655 9-5-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18 How were dimensions determined? Asbuilt-Tape Sludge Judge 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 at working level.Tank and covers at 8" below grade, Inlet tee, Outlet baffle. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass 0 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 LSins.doc rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System ?ape 10 of 17 �� a5ed xed dH 9t7:ZZ L 60Z 90 daS r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli .Owner Owner's Name information Clulradred is for every rOsterville MA 02655 9-5-16 eq page. City/Town State Zip Code Date of inspection D. System Information(cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Dad .Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No I5ins.doe•rev-W 6 Title 5 Offide]Inspection Form:Subsurfaoa Sewage Disposal System-Page 11 of 17 Sti abed xed, dH gt,:ZZ L 60Z g0 d@S f - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Sharon Circle Property Address . Lillian Maselli Owner Owners Name information is required For every Osterville MA 02655 9-5-16 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No` Comments (note condition of pump chamber, oondition of pumps and appurtenances, etc.): `If pumps or alarms are not in working order, system is a conditional pass. Sall Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why. 15ins.doc ray.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 17 9t a6ed Xed• dH Lt,:22 L l,02 g0 daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owners Name information is required for every Osterville MA 02655 9-5-16 page. City/town State Zip Code Date of Inspection D. System Information (cont.) Type. ® leaching pits number: 1 ❑ leaching chambers number; ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overnow 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.): Leaching is a 1000 Gal. Precast Pit. Pit and cover 26" below grade. 6"water in pit wlstain line at 2'. No sign of over loading or solid carry over. No high stain line. 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 15ins,doe-rev.6116 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 17 Lb a5ed Yed dH Lt,:ZZ L 60Z g0 daS Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name information is required for every Osterville MA 02655 9-5-16 page. City/Town state Zip Code Date of Inspection D. System Information (cost.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.). Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.&'1 B Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 g� abed xed dH LtrZZ L 60Z 90 d8S I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name information is required for eery Osterville MA 02655 9-5-16 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately GJ ijT A t5ins.doc•rev.6/16 Tice 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 6t7 a5ed xed dH &ZZ L 60Z g0 daS i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ` 48 Sharon Circle Property Address Lillian Maselli Owner Owners Name information is required for every Osterville MA 02655 9-5-16 ipage. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N� 20'+ Estimated depth t high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation.hole within 150 feet of'SAS) ® Checked with local Board of Health-explain: per past report. ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Abutting property and rear property and past report. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Isis .doc-ray.slt s Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 18 0117 05 a5ed xed dH 8t,:ZZ L 1,0Z g0 daS f 0 Commonwealth of Massachusetts • Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name information is required for every Osterville MA 02655 9-5-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ine.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage DiSposel System•Pege 17 of 17 . l S a5ed xed, dH BVZZ L 60Z 90 d@S No. fx��'"1 ' Z / Fee la) THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitation for Disposal *pstem ConstCUCtion Permit Application for a Permit to Construct( ) Repair(k) Upgrade( ) Abandon( ) ❑Complete System Lid Individual Components Location Address or Lot No. �Ci 5`�.j� G tP_C j1_-­ Owner's Name,Address,and Tel.No. 0 5rc-_7"Jf L([. i AYJ AKA 5 r;L-o Assessor's Map/Parcel ' a ( S GF QJ O l c Installer's Name,Address,and Tel.No. 50S-t{77-22-C7 Designer's Name,Address,and Tel.No. co4�Ewi�c �►"�2i�� �.c.�l5 Nlq 96 QX S c tP6-9 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(min.required) 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) �/ RcP � 6 0 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 Certificate of Compliance has been issued by this Board of HealtlL Signed Date 10 7 Application Approved by Date 10 -L iQ- Application Disapproved by Date for the following reasons Permit No. -)L0)7'?j-7 Date Issued - - -----_-_____ --- No. tJQ "f Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Misposal 6pstem Construction permit Application for a Permit to Construct( ) Repair K) Upgrade( ) Abandon( ) ❑Complete System kl Individual Components Location Address or Lot No. 7 Q 5(4o(kW GCQ.C%C+C Owner's Name,Address,and Tel.No. D Assessor's Map/Parcel Sti`'�i Jlt�ct as ( ' $ S GF, p� CACLu OSZIIc I4ler's Name,Address,and Tel.No. 5 OS-I¢77�'9'f T7 Designer's N,lame,Address,and Tel.No. P�wipc N�/'i 15 3 G( ClG! Cl s'r wlrFStfD�-� 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. I Description of Soil I Nature of Repairs or Alterations(Answer when applicable) RePLACz-, art. � Date last inspected: j 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 1not to place the sykem in operation until a Certificate of Compliance has been issued by this Board of Hea Signed `�-..� , ' Date Application Approved by L Date 10 ' '/4 s ;',3 Application Disapproved by i Date 1 for the following reasons r Permit No. a� ` J� Date Issued - _. - i THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS x Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by CAP GW l o6 tFo rj9tPO4<&� C.�.G at di 11 Tg s OARotJ C(P. 0S 7GW1C(_C— ..has been colTIcted in accc}orO e with the provisions of Title 5 and the for Disposal System Construction Permit No. '}® dated } dAP&W t Installer Z 67_-jeDEP,4ls6T („LG.. Designer NA #bedrooms Approved design .ow i' NA P gpd a j17 1i The issuance of this'permit s al"not bJ construed as a guarantee that the system will function as designed. f Date ' r /l C Ins ector No. `t' Fee / 0 1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION.-BARNSTABLE,MASSACHUSETTS MIsposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(A) Upgrade( ) Abandon( ) System located at q-g SHAp b&) G'IQC4j_- and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with j Title 5 and the following local provisions or special conditions. Provided:Construction must /b�e completed within three years of the date of this permit.d�G Date V �y' Approved by /'' YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FI-, 367 Main St., Hyannis, MA 02.601 (Town Hall) and get the Business Certificate that is required by law. ,I., _ DATE: � 8 �v Fifl in please: jww 1V, ':r` I APPLICANT'S YOUR NAME/S: / A11 _S _ BUSINESS YOUR HOME ADDRESS: S SOY �r""` e5lL?►'�::i TELEPHONE # Home Telephone Number OR EIN S E-MAIL: J�' (C l - L �e ;N ��•°� NAME OF CORPORATION: NAME DF,NEW BUSINESS ,0/1/ /r/ UE TYPE OF BUSINESS IS THIS A HOME OCCUPATa N? YES NO / ADDRESS OF BUSINESS. e1 S dG s1,0-0,?�AP/PARCEL NUMBER f.�� ��� (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you In obtaining the information you may need. You MUST Go TO 200 Main St. - (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. MUST COMPLY' WITH HOME OCCUPATION 1. BUILDING COMMISSION OFFICE RULES AND REGULATIONS. FAILURE TO This individual has b infor of any p r quiremerits that pertain to this type of business. COMPLY MAY RESULT IN FINES, Ntl ed Signatu a** CO MENTS: " 2- BOARD OF HEALTH-5 This individual has been infor ed a permit requirements that pertain to this type of business. Authorized n e** COMMENTS: 3. CONSUMER AFFAIRS [LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: - - I ct 09 1410:08p p.1 Commonwealth of Massachusetts Title 5 Official Inspection Form a' = Subsurface Sewage Disposal System Form- Not for Voluntary Assessments - 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name information is required for every Osterville MA 02655 10-9-14 page. Cityrrown 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:When A. General Information filling out forms • on the computer, I ( ` �rOFrM use only the tab 1. Inspector: I .�`���y��`' • A�`�9 key to move your cursor-do not James D.Sears JAMES 'yN use the return key. Name of Inspector _�; EARS = .�:• Coz CapewideEnterprises,LLC , �., Company Name — - �f' •RTIf� ••O �` 153 Commercial Street - �,�, Company Address if Mash pee MA 02649 CityfTown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification 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 6(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 10-9-14 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. "'This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of.use. o Z�I I t5ns•3713 a- Title 5 OOida!r.�Vb. ee Sews D' S m•P s9B isposal ys ge 7 of 17 Oct 091410:08p p 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owners Name - — information is required for every Osterville MA 02655 10-9-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) 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: The system is a 1000 Gal. Tank D Box and ph. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to.be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved.by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15ins•3113 Tine 5 oXcial Inspection Form:Subsurface Sewage Disposal System Page 2 of 17 vut vy 1'+ i u:uap p.3 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for VoluntaryAssessments k 48 Sharon Circle v? Property Address Lillian Maselli Owner Owner's Name information is required for every Osterville MA 02655 10-9-14 page. Cityrrown Stale Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled,or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ .Y' ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment;- El Cesspool or privy is within 50 feet of a surface water - ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3f13 Title 5 oRicial trspedlon Form:Subsurface Sewage Oisposai System•Pape 3 of 17 vct vy 1'+ 1 U:uap p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System - Not for Voluntary w stem F N Assessments 48 Sharon Circle Property Address Lillian Maselli Owner information is Owner's Name required for every Osterville MA 02655 10-9-14 page. City/Town State Zp code Date of InspeWon B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of,a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"a. . Method used to determine distance: "" This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: k D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in Is less than 6"below invert or available volume is less than day flow 15ins-3P 3 TNe 5 official Inspedon Form:Subsurface Sewage Disposal System-Page 4 of 17 %JUL uV I-+ l u:uyp p.5 Commonwealth of Massachusetts. y - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name information is required for every Osterville MA 02655 10-9-14 page. Cftyrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area —IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 T01e 5 Official Inspection Form:SuCsurface Sewage Disposal System-Page s or 17 Oct 09 1410:09p p,g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name information is required for every Osterville MA 02655 10-9-14 page. CityfTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑. Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Mns-3113 Title-5 Official Inspection Form Subsurface Sewage Disposal System-Page 6 of 17 Oct 09 1410:10p - P•7 Commonwealth of Massachusetts Title 5 Official Inspection Form kvSubsurface Sewage Disposal System Form - Not for Voluntary Assessments �w 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name information Is required for every Osterville MA 02655 10-9-14 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal.Tank D Box and Pit. Number of current residents: 1 — Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (include laundry-system inspection ❑ Yes ® No information in this report) Laundry system inspected? ❑ Yes R No Seasonal use? El Yes ® No Water meter readings, if available last 2 ears usage 2012-18,000Gals g ( Y 9 (9Pd)) 2013-22,000Gal's Detail: • Sump pump? ❑' Yes ® No Last date of occupancy: Present Date Commerciallindustrial Flow Conditions:' Type of Establishment: — Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft. etc.): Grease trap present? ❑. Yes ❑ No Industrial waste holding tank present? P ❑ Yes ❑ No 'Non-sanitary waste discharged to the Title 5 system?~° ❑ Yes ❑ No Water meter readings, if available: 15ins•3113 Tltla 5 Olricial Inspection form:Sthstsfece Sewage Disposal System-Page 7 or 17 Oct 091410:10p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name information is required for every Osterville MA 02655 10-9-14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cons) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins 3113 Tille 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 8 of 17 Oct 09 1410:10p p•9 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name -- information is required for every Cisterville MA 02655 10-9-14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: NA New D Box 10-2014 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1 g^ Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: f --- • feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) t 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. Precast H-10 Sludge depth: 211 15ins•3/13 Tice 5 Offidel Inspection Form:Subsurfsoe Sewage Disposal System-Page 9 of 17 Oct 09 14 10:11 p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owners Name information is Osterville MA 02655 10-9-14 required for every - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cunt) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Slud9 a Judge 9 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 at working level.Tank and covers at 8"below grade. Inlet tee,outlet baffle. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: Beet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Officid Inspection Form:Subsurface Sewage Disposal System-Pap 10 of 17 Oct 09 14 10:11 p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4B Sharon Circle Property Address Lillian Maselli Owner Owner's Name information is Ostemlle MA 02655 10-9-14 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.). Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ire-3113 Title 5 Official Inspectim Form:Subswface Sewage Disposal System-Page 11 of 17 UC1Wj 14'1U:"11p p 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name information is required for every Osterville MA 02655 10-9-14 page. Crtyffown State Zip Code Date of Inspection D. System Information (cont.) . Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids canyover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-21" below grade wlcover at 4" D Box is New 10-2014 Won' line out Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order. ❑ Yes ❑ No` Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order,system is a conditional pass. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located, explain why: t5ins•3113 T1l8 5 0Mdal k"Wbw Fern:Subsurface Sewage Dleposel System-Pepe 12 d 17 vul vy I + I v. 1 cp p.13 Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam -Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Masellt M1 Owner Owner's Name informabon is required for every Osterville - MA 02655 10-9-14 page. CltyfTcwn Slalte . ZAP Code Date of Inspection D. System Information (cunt.) Type. ® leaching Pik number. 1 ❑ 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.): Leaching is a 1000 Gal.Precast Pit. Pit and cover 26"below grade. 18"water in pit w/stain line at 2'. No sign of over loading or solid carry over. No high stain line 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 constriction Indication of groundwater inflow ❑ Yes ❑ No 15ins•3113 Title 5 Official Inspedon Frnm:Subsurface Sewage Disposal Syslem-Papa 13 of 17 vvL V.7 I-t IV. I4y _ p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name Information is required for every Osterville MA 02655 10-9-14 page. cltyr town State Zip Code. Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15tns•W 3 Title 5 olf cid Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 vlR UV 14 1 V. I Lp p.15 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Sharon Circle Property Address Owner Lillian Maselli information is Owner's Name required for every Osterville page, Uty/Town MA 02655 10-9-14 sM& Z1P Code date of fnspectian D• System information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate where public water supply enters the building. Check one of the boxes below: E f� ® hand-sketch in the area below _e _ ice— i;tit?P fLl n-- — - tNns.3113 - - Tiee 5 Offrdal i.nspeCfti Form:SuDsLAWO Sewage Disposaf Sysyer„.page 15 of 17 y - Oct 09 1410:12p p.16 commonwealth of Massachusetts Title 5 Official Inspection Form _ a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name Informatlonrequired is Osterville MA 02655 10-9-14 required for every page. CIt rrrown State Zip Code Date of Inspection D. System Information (coat) Site Exam: ❑ Check Slope ❑ Surface water " ❑ Check cellar ❑ Shallow wells Estimated depth t 20+ p high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting propertylobservation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: per past report ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain. You must describe how you established the high ground water elevation: . Abutting property and rear property and past report Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 6 Dlfic4d Inspection Fam:Subsurface Sewage Dispose)System-Page 16 of 17 Oct 091410:13p . p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 48 Sharon Circle Property Address Lillian Maselli Owner Owner's Name Information is psterville MA 02655 10-9-14 required for every State Zip Code Date of Inspection page. City/Town E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 15ins-3113 Title 5 diridal Inspection Fomr..Subsudece Sewep Disposal System•Pepe 17 of 17 COMMONWEALTH OF MASSACHUSETTS d . EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION v� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 48 Sharon Circle Osterville MA 02655 ® —a Owner's Name: Lillian P.Maselli Owner's Address: Same c— za Date of Inspection:June 11,2005 Job#05-164 `� � c. 773 Name of Inspector: PATRICK M.O'CONNELL Company Name: SEPTIC INSPECTION SERVICES CO. Mailing Address: 189 CAMMETT ROAD n-) MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 `o rn 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 D t11111111p approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: OF Passes Conditionally Passes _ TR C ccn Needs Further Evaluation by the Local Approving Authority �, M E c Fails Inspector's Signature: — Date: June 11,2005 5/� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments: Observed 18-24"standing water in leaching pit,high stain lines indicate pit has never been more than half full. ****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' r 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: 48 Sharon Circle Osterville MA 02655 Owner: Lillian Maselli Date of Inspection: June i i,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ 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: Title. incnonfinn Fnrm Aii si,)nnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 48 Sharon Circle Osterville MA 02655 Owner: Lillian Maselli Date of Inspection: June 11,2005 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. r _ 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: T;+1.C Tnc--,tinn Rnr fli 4�1,Tnnn - 3. Page 4 of I I j OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 48 Sharon Circle Osterville MA 02655 Owner: Lillian Maselli Date of Inspection: June l 1,2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ 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 Systems: To be considered a large system the system must serve a facility with a design flow of 10,060 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—I WPA)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 g y s failed.The owner or operator of an large system cons'P Y g Y 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. Tit1P ';incnnrtinn 17nrm 411 v7nnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'B CHECKLIST Property Address: 48 Sharon Circle Osterville MA 02655 Owner: Lillian Maselli Date of Inspection: June 11,2005 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes. No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _ _X_ Were any of the system components pumped out in the previous two weeks?- _X_ _ Has the system received normal flows in the previous two week period? _ _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X_ — Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ 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? _X _ 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 _X_ _ Existing information. For example,a plan at the Board of Health. X_ _ 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)) Titles Q TncnPrtinn Fnrm Ail 4;mnnn 5 r Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 48 Sharon Circle Osterville MA 02655 Owner:. Lillian Maselli Date of Inspection: June 11,2005 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: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): N/A Seasonal use:(yes or no): Yes Water meter readings, if available(last 2 years usage(gpd)): 2003—25,006 gal.2004—25,000 gal.=68 gpd. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: Pumped 2-3 years ago. Source of information: Homeowner 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: Compliance date: May 30, 1986 Were sewage odors detected when arriving at the site(yes or no): No Title Rnr Ail vinnn 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: 48 Sharon Circle Osterville MA 02655 Owner: Lillian Maselli Date of Inspection: June 11,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' Materials of construction:_cast iron _X_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: XX (locate on site plan) Depth below grade: 1' Material of construction:_X_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:8.5' long x 5.2'wide- 1000 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 27" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Baffles intact and clear,liquid level at bottom of outlet invert GREASE TRAP: No (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.): Title C Tncnartinn 1+'nrm�n Ci�nnn 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: 48 Sharon Circle Osterville MA 02655 Owner: Lillian Maselli Date of Inspection: June 11,2005 TIGHT or HOLDING TANK: No (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: No (if present must be opened) (locate on site plan) r Depth of liquid level above outlet invert: - Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: No (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): T41. S TnctlPrtlnn P.' 4i1;i,7nnn 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: 48 Sharon Circle Osterville MA 02655 Owner: Lillian Maselli Date of Inspection: June 11,2005 SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type —X_leaching pits,number: One 6x 6 Pit 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.): Observed 18-24"standings water and a high stain line one foot above current level CESSPOOLS: No (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: No (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.): T41.G Tncnortinn Rnr 4/1 G/innn 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: 48 Sharon Circle Osterville MA 02655 Owner: Lillian Maselli Date of Inspection: June 11,2005 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. Driveway 54 15 Garage #48 31 29 Titlo C incnAntinn Fnrm�ii ci�nnn 10 Page 11 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 48 Sharon Circle Osterville MA 02655 Owner: Lillian Maselli Date of Inspection: June 11,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 20 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.30 and topo map shows property above el.50. a Titles i TncnArtinn Fnrm A/1,;/7nnn 1 I TOWN OF BARNSTABLE LO�A ION V6 ,-5hw-Qn SEWAGE # - 1-A-004n VILLAGE ds �rJ�9�� _ASSESSOR'S MAP & LOT ff S NAME& PHONE NO. __ e Y�u� VLon AI ��l7'7�/ SEPTIC TANK CAPACITY 1006 LEACHING FACILITY: (type) {�1�� (size) /U4w� NO. OF BEDROOMS BUILDER OR<IOP, Ldbcn Ma5 e,III PERMITDATE: C04 E DATE: Cr3 t 6 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 ,,, �-�y �? IS �I �� �y� �� z�i .... �'.. �a 4 No.......6....j�� - Fps........................... THE COMMONWEALTH OF MASSACHUSETTS- BOARD OF HEALTH wn/. .......OF......./ n1 Tj G ................................ Appliration for DiipnsFal Warks C onstrurtiun ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at -5f/�/,/ 0/ec1..Gr O.,S�j21/�l�G �T " �7 ................_...---- ................. ...........---•--•-----•-•----•----•--...---.....• •••--••-••--••----•-----•••---..........------•---•---•--•-••--•............................---... Location AM,-w 1/✓bI2C./�... 4 -Addres 0 �/ 47�7'l�s✓ �3�� ............................. ..._ ...................................... .�..... caner Addressl j ------------ . .................... ...... ..--••-•------•----- -- Installer Address 3 d ype of Building Size Lot...Z-3--.- ...3..___/ 2......Sq. feet Dwelling—No. of Bedrooms...........3........:....................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type T e of Building No. of persons............................ Showers A.i YP g ------•--------•------------ P ( ) — Cafeteria ( ) Q' Other fixtures .........................••--••---•--•-------- W Design Flow................-` ................... per person per day. Total daily flow...............33a.....____.__....__gallons. WSeptic Tank—Liquid capacity_;t�...gallons Length.�'C`:.... Width.¢'�....... Diameter________________ Depth..s'(6��- x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.......e.e........ Depth below inlet.....6...._._._._. Total leaching area...!.7__....sq. ft. Z Other Distribution box ( ) Dosing tank aPercolation Test Results Performed by.--'72 ! �______fir__.-.A�- .OV............ Date... ^! �y �g�..___ Test Pit No. 1...�_.Z._._.minutes er inch Depth of Test Pit...t�?..... /p p _ _ _ Depth to ground water_...._."-'._..._..__-. 44 Test Pit No. 2_..L z....minutes per inch Depth of Test Pit...l ...... Depth to ground water----- ............. a+ ............................................................. �5��-Sei t. --------? „-/ 4iG • �' .. U .S'Gl�/� ----•----------------------•---------•----------------•-----------------......--•------.........-----........_------------• 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 A ITI U 5 of t e State Sanitar ode—The undersigned further a rees not to place the system in operation until er at of m liance haZce issued by the bo of h lth.ned �?�!...._ -_ �2�DateApplicatio p v BY7 •-----•. •-•-•- -- .. .... Z g Date Application isapproved for the follow n reasons-------------------------------............................................................................ _.._ Date Permit No........ 3-------------------- Issued........................................................ Date No.. ............_....... FEE..................._..... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.........-.................................. App irtt#ion for Dhip sal Workii Tonstrur#ion rruti# Application is hereby made for a Permit to Construct (4,1 or Repair ( ) an Individual Sewage Disposal System at: ....:..........._................................................................................ •-•--....._....-•-••---•••••••-•-••••---••-•-•--•..._.....••••-•------......__...........___-----• Location-Address or Lot o. -• \ �y ...... .........•.-j---� J r............. -ss �•� ---^ ------•-•----••••..... ••----. -•-••............... Installer Address Type of Building7� .� Size Lot.......-'..-......:.........Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of ersons____________________________ Showers � YP g -•-•------------------------ P ( ) — Cafeteria ( ) dOther fixes -••-• ...................................`...........................................................3.3ci.............................. W Design Flow......................_.___......:__:___________gallons per person per day. Total daily flow............................................gal lo s, WSeptic Tank—Liquid capacity_!O"'."__gallons Length_ �e__.__._ Width__`6._ ___ Diameter________________ Depth__S____........ x Disposal Trench—No_ ____________________ Width................... Total Length._______.___._ Total leaching area....................sq. ft. Seepage Pit No.______�_---------- Diameter......./p....... Depth below inlet___.._G........._. Total leaching area.._. .....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.. :?31�!ihc9> `r4C--.�/ t'J a ------------------------------ _, /• • Date Test Pit No. 1___ .?._._minutes per inch Depth of Test Pit____ ; __ ____ Depth to ground water..___.: ____.....__. f=, Test Pit No. 2______ ________minutes per inch Depth of Test Pit._.__. __________ Depth to ground water______7............. W ...............----- ............................................•------..._-----•-----------•----___:-------•-•-•--___--------•----•--------•---------- 0 DescSi tion of Soil............. .__-� '•_ v✓aUG�-�"a-�-a ... J . Sod 7�"- /4� „ l za//G°G�i2sC V .....-•-----------------------------------------•---••---....•--..---------•-----•--•-----...----__...-•-•-•------------.._...-----------•---•--------•--•-----------------...--•--•...._..•------------- W ----•---------- ----------------------------------------------------------------------------------------------------------------------------•------------------------------..._..---•---._...._.._..---- V 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 TITI.1 5 of t e State Sanitar,7'_" _ode—.The undersign urther agrees not to place the system in operation until r e of m fiance hasbeen issued by the b of heallth.� Z ed..-. - . . .. ...... ..............................�Z ....•.... r� A- licatio A v B ..--- ---'�-•1--��---�" -••----- -/-�Z-a-e� PP P Y --•- Date Application Disapproved for the followi reasons:............................................................................................................. - •-•--•--•-----•-•-•-•-•-•••••----•••---•-•....--•----•--••-•••---•---••-•-•••--•-•-...--••---...-•--•--••-------•..................•--------•-------• .................................................. Date PermitNo........ �� ��� -------••-••-•---. Issued_....................................................... Date .THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH awn/ Trr#ifirtt#r of Toutplittnrr \ 'HIS ERTIF d vi al -wagDl S s constructed or Repaired J� h C ga ( ( ) by . /....... .••••--_. ...•••... . ........... �I Lo t *.47 J�GVI �v`- zG' � � ? V J (.7 .................................. ---------------------•------------..... / e ..„• _________Ins t -----•--••-•••-••------ -•-•••--••---------r-.._..----•-•-•-•--...•-••........................ has been installed in accordance with the provisions of TITLE 5 of h tate Sanitary Code Zs d crib d in the application for Disposal Works Construction Permit No______________ ____,.. dated............ �_._!___ ... ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NO BE C NSTRUED AS A GUA AN EE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE 3 --__------_-•---------------- Inspector -.::: !'..--......_.........---......--•---•-----•--••----•-----•----...----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH' �` 7a kiioi c c- cf No.........................---'-� __�--� ..- Disposal Wrks To druawn In=t# c- Permission is hereby granted....... .................................................�' /........................................................................... to Construct (✓j o Repair ( ) an Individual Sewage Disposal System at No................ �l i_r Street t r7 as shown on the application for Disposal Works Construction Permit No �.. t�.�`aatteed.._.Z_....... r _..`_6................. a Y.� Bo r of Health DATE-------- -------• •-----••-._..._•-•---•-•-._.....f?..__......_ FORM 1255 A. Ni'`S• LKIN, INC., BOSTON �'.� r SNP T af= Z. S<1cCz�-T5 4 Sf/fl,t2a n/ � Ci.ecLE i / ZoT04G 47,i ` %) • ,fig + 231 319 ,5f,F7-, LoT 48 Hole i ell 24 t r-u-rv. rnp ni ORopoS" n, 4 t Ti✓v4 c 4.5.30 ' �.'. t 00 _JJT Z17 z8 rop aF srq�c6= 4S,a z NoT� - YAT/uNS B. S�7'� o^� i9ssvM� DA-rz..y, LOCATION .O.S77�✓iGLG" /`1/�SS SCALE . :� '�. . . DAM .?�•!9B G, PLAN REFERENCE . .. 47 EnWIN "yLLEY b r10. 26100 ,o . . . . . . . . . . . . . . . . . S1FR�`� I CERTIFY THAT THE A LA��� SHOWN ON THIS PLAN 19 LOCATED ON THE GROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF . . . • WHEN CONSTRUCTTD. DATE • . . . . . . . .. . REGISTERED LAND SURVEYOR i `. SNOT z aF z sN�ETS _ L 4S. 30. . • TOP OF FOUNDATION I CONCRETE COVER CONCRETE COVERS . . Z.401 ; 4"CAST IRON 2"MAX. T 12"MAX. ,.. P-V-C- PIPE SCHEDULE 4� 4"SCHEDULE 40 PV.C.(ONLY) PITCH 1/4'PER. PIPE- MIN. LEACH PITCH 1/4"PER.FT. PIT PRECAST I� -r LEACHING ••• EL !�TB,6•• INVERT INVERT : . ; PIT OR SEPTIC TANK zir/g DIST, qp W t;c EQUIV. , INVERT EL..�. .. . .. BOX EL • `f. ' : > EL.. ?;�.�.. �ooc' GAL• INVERT INVERT 6 w w Q' ::% 3/4"TO I V2� EL;x•m. i LL� WASHED W . STONE ►.� /o, � 8 � ii �Z.3S.90 ',. /L --•�� 6 DIA. /o' DIA. sree a PROR LE OF 767110NF WATER TABLE SEWAGE DISPOSAL SYSTEM ' NO SCALE SOIL LOG WITNESSED BY : DATE TIME. ��:°O '`�'� . 'T�'' �"��"/. BOARD OF HEALTH TEST HOLE I TEST HOLE 2 ,•L�G✓ D, • ,ee-zLE^/, , ENGINEER 1Nooplo P/7 7;Wrr . . . . . . woo 4a4/'7 . . I¢N see-so�� ?Aft S�Bso.�. DESIGN DATA : MAD NUMBER OF BEDROOMS . . . . . . . . . . . . . . . Le" 3 AZn3B,fo TOTAL ESTIMATED FLOW . , _330. • GALLONS/DAY GENE ' 'y�/cea,2s tr 9i„ Sq vD BOTTOM LEACHING AREA 78'S°. . SO.FT./PITla,P, D. `2.3✓!�jo SIDE LEACHING AREA . . . �BB'.So: . SO.FT/ PIT/47/G.PD, Cpsh2S� GARBAGE DISPOSAL NO!k�4..(50% AREA INCREASE) S,q�o TOTAL LEACHING AREA SO.FT GsL. /o �Z. 3/.90 PERCOLATION RATEs-s /�^: n✓o MIN/INCH 33, %44" LEACHING AREA PER PERCOLATION RATE .A-4�70.. SQ.FT./c,RD. No-WATER ENCOUNTERED NUMBER OF LEACHING PITS RT• yt/ 77/• APPROVED . .. . . :. . . . . BOARD OF HEALTH Y• `•�-rr OF`S ONt� Oc/•042�• SiJ>ES . DATE. . . . . . . . . . . . . . . . . . . AGENT OR INSPECTOR H OF EN AA Lo 7- `t¢7 N . . . . . . . . . . . . . . . . . . . ELLEY �' No. 26100 4>S7 7Z I//GG e i� SgNRAR\P� PETITIONER ASSESSOR'S MAP 0. PARCEL'�� 06— /0-�3 E0 CA T 10H � � Iw G F P VIAA1T Na. V1, LLA i f Vl oz I N S T A LLEK'S A ME A.DDRESS A co UiLDEk OR OWNER 0 OATS COMPLIA ;10E I S S U ED 6/S6 IN 9 s� LM4 q� . � �zk � 3 ---- 11 '��5- �/� T ION_��Z S E W A G E PE RMIT NO. VILLAGE I N S T A JYER'S NAME g XDDRESS BUILDER OR OWNER 41/ DATE PERMIT ISSNED DATE COMPLIANCE ISSUED 13 .� //: race /moo AV 1 a