HomeMy WebLinkAbout0024 SOUTH STREET - Health 24 South Street
Osterville
A= 118-058
3
TOWN OF BARNSTABLE
1:
LOCATION o2 '5 5 SEWAGE # Apip- q1 G
VII,LAGE ASSESSOR'S MAP&LOT/1 F S l-
�C
INSTALLER'S NAME&PHONE NO. ofr-ef R.Olw l O o IL",SD F 3.2-CAS 30
SEPTIC TANK CAPACITY /-S-O U
LEACHING FACILITY: (type) - 5 boa �n c� (size) 33
NO.OF BEDROOMS Al
BUILDER OR OWNER
PERMITDATE: 9 ( I I (o COMPLIANCE DATE: r 0 I a
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility A/'O Feet
Private Water Supply Well and Leaching Facility (If any wells exist ,,/
on site or within 200 feet of leaching facility) 4 0 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist ^,////ll
within 300 feet of leaching cili ) /w Feet
Furnished by�/
A-a =ao ' ell>
A- 3
-! t q 3
� P
C^ y ; 3y . ., o o O .
A 4`6" �' °�► O 3
A „y = 16.1
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Commonwealth of Massachusetts
M1 W Title 5 Officiall Inspection Form
m, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
24 South Street
Property Address
Gary Gleason
Owner Owner's Name
information is required for every Osterville MA 02655 11/14/13
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:when filling out forms A. General Information
on the computer,
use only the tab 1. Inspector: I n
key to move your t �{�
cursor-do not James Ford
use the return key. Name of Inspector
i
Company Name
P.O. Box 49
Company Address
Osterville MA 02655
City/Town State Zip Code
508-862-9400 S 12482
Telephone Number License Number
1
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 ❑:`Conditionally Passes ❑ Fails
is
❑ Needs Furthe E aluatiotn by the Local Approving Authority
11/14/13
Inspe o's Signature Date
The Uem 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.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Officiate Inspection Form
Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments
^M 24 South Street g '
Property Address ,
Gary Gleason
Owner Owner's Name
information is required for every Osterville MA 02655 11/14/13.
page. City/Town State Zip Code Date of Inspection
B. Certification (cont)
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:
a
B) System Conditionally Passes: =a
❑ 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):
I,
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
s y.
t'
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 24 South Street
Property Address
Gary Gleason
Owner Owner's Name
information is required for every Osterville MA 02655 11/14/13
page. City/Town State 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 (cost.):
�t
❑ Observation of sewage baokup 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) arereplaced ❑ Y• ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N `❑ ND (Explain below):
❑ distribution box ib- Ieveled,or replaced ❑ Y ❑ N ❑ ND (Explain below):
t�
❑ 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):
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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:
d
Il ;
❑ 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
(Sins•3/13 f :Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
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Commonwealth of Massachusetts
Title 5 Official" inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
24 South Street
M -
Property Address
Gary Gleason
Owner Owner's Name
information is required for every Osterville MA 02655 11/14/13
page. City/Town i 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 sepfic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic'ta'nk and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determin'e'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:
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D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" 6r"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
El ® 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
El ® Liquid`depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
�•
Commonwealth of Massachusetts
Title 5 Official; Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 9
°M 24 South Street
Property Address
Gary Gleason
Owner Owner's Name
information is required for every Osterville MA 02655 11/14/13
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.) {
Yes No ~
❑ ® Require'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.
1,
❑ ® 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 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 CAain 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.
„ l
E) Large Systems: To be cori'sildered a large system the system must serve a facility with a
design flow of 10,000 gpd toa15,000 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
's I
❑ ❑ 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—'9WPA)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 Sectiori: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 3!10 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
(Sins•3/13 it a Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
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Commonwealth of Massachusetts
Title 5 Officia[Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.r
24 South Street
Property Address f g
Gary Gleason {
Owner Owner's Name
information is required for every Osterville MA 02655 11/14/13
page. CityrFown State Zip Code Date of Inspection
C. Checklist
i
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:_
Yes No
r'
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were ariy of the system components pumped out in the previous two weeks?
❑ ® Has the;system received normal flows in the previous two week period?
El
® Have large volumes of water been introduced to the system recently or as part of
this insp{ection?
® El 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 th64 site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were thy,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?
El ® 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:
Z - ❑ 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
approxirpation of distance is unacceptable) [310 CMR 15.302(5))
D. System Information
Residential Flow Conditions:
Number of bedrooms (desigb,): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
4
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t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r,
i
24 South Street
Property Address
Gary Gleason
Owner Owner's Name r
information is yy x
required for every Osterville 4 '. MA 02655 11/14/13
page. City/Town i State Zip Code Date of Inspection
D. System Information
Description:
Qk))
p'
Number of current residents:; 0
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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? El Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
unavailable
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Sump pump? 1. ' ❑ Yes ® No
Last date of occupancy: _ ' Da known
h
Commercial/Industrial Flow Conditions:
Type of Establishment: .I
t
Design flow(based on 310 CUR 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? ❑ Yes ❑ No
Non=sanitary waste discharged to the Title 5 system? El ElNo
t :
Water meter readings, if ava�jiable:
t5ins•3/13 1 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
i
Commonwealth of Massa'chusetts
Title 5 Official`, Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 24 South Street
Property Address
Gary Gleason `
Owner Owner's Name
information is required for every Osterville MA 02655 11/14/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
1 4-
# General Information
r,
Pumping Records: '
Source of information: unknown
Was system pumped as parfof 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
El 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
4 inspection of'the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official ;lnspection Form
Subsurface Sewage Disposal 8;iptem Form - Not for Voluntary Assessments
°M 24 South Street
Property Address t'
Gary Gleason
Owner Owner's Name
information is required for every O MA 02655 11/14/13Stervllle ��
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
installed - 10/26/10 - per as-built card
Were sewage odors detected when arriving at the site? . ❑ Yes ® No
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
Comments (on condition of joints, venting, evidence of leakage, etc.):
n
}
Septic Tank(locate on site plan):
Depth below grade:
16
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
i
If tank is metal, list age: " years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: I 1500 gals.
` 211
Sludge depth:
t5ins•3/13 I Title,5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
J '
fl
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' M 24 South Street
Property Address
Gary Gleason $
Owner Owner's Name
information is I .i
required for every Cisterville , . ; MA 02655 11/14/13
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
Scum thickness
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
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet.invert, evidence of leakage, etc.):
The tees were present. There was no sign of leakage.
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Grease Trap (locate on site plan):
Depth below grade: f; feet
Material of construction:
t.
❑ concrete ❑ metal ,; ❑fiberglass ❑ polyethylene ❑ other(explain):
N/a
k •
Dimensions:
Scum thickness
t '
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
t5im•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
M
e .
Commonwealth of Massaiiclpusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
24 South Street
Property Address
Gary Gleason
Owner Owner's Name
information is
required for every Osterville r MA 02655 11/14/13
page. CitylTown ; 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.):
F
t
Tight or Holding Tank tank must g g ( be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
El concrete ❑ metal El fiberglass
polyethylene El other(explain):
N/a
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: El Yes ❑ No
Date of last pumping:. Date
Comments (condition of alarm and float switches, etc.): t
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal system Form - Not for Voluntary Assessments
M 24 South Street
Property Address
Gary Gleason
Owner Owner's Name
information is required for every Osterville MA 02655 11/14/13
page. City/Town State Zip Code Date of Inspection
D. System InformatioKi (cont.)
Distribution Box(if present�must be opened) (locate on site plan):
i �
Depth of liquid level above outlet invert even
Comments (note if box is level`and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out'of box, etc.):
The D-box was normal.
Pump Chamber(locate on site plan):
Pumps in working order: ,' ❑ Yes ❑ No"
Alarms in working order: fj ❑ Yes ❑ No"
I
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/a
n
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:
�I a
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l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Officials': Inspection For
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i
24 South Street
I
Property Address f
Gary Gleason
Owner Owner's Name
information is required for every Osteryille MA 02655 11/14/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits_`; number:
3-500 gal.® leaching chambers number. 12.8'x33'x2'
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The chambers were dry and Iean.There was no signs of failure. A camera was used for the
inspection.
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Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/a
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scumi layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 24 South Street
Property Address
Gary Gleason
Owner Owner's Name
information is required for every Osterville MA 02655 11/14/13
page. CitylTown 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.):. ; t
l t
Privy(locate on site plan):
Materials of construction:
Dimensions It
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): ,
N/a
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t5ins•3/13 jt ` Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17.
• Commonwealth of Massaphusetts
Title 5 Official; Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 24 South Street
Property Address '
Gary Gleason
Owner Owner's Name _
information is required for every Osterville . MA 02655 11/14/13
page. CitylTown State Zip Code Date of Inspection
D. System Information cont.
Y (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
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15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
• • Commonwealth of Massachusetts
W Title 5 Officials Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
24 South Street
M ,
Property Address
Gary Gleason
Owner Owner's Name
information is Osterville y MA 02655 11/14/13
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells i
Estimated depth to high ground water: 48
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date,ofi design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Using topo and water contours maps
❑ Checked with local excavators, installers'-(attach documentation).
❑ Accessed USGS database*-explain:
You must describe how you'established the high ground water elevation:
, r
see above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i
wM 24 South Street
Property Address
Gary Gleason .
Owner Owner's Name ! '
information is required for every Osterville MA 02655 11/14/13
page. Cityfrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, 13;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
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t5ins•3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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Town of Barnstable P#
Department of Health,Safety,and Environmental Services
VE Public Health Division Date
oT 367 Main Street,Hyannis MA 02601
• BARNSTABI.E, ' _-
MASS.
i639. /Uv
°ren Mn+" Date Scheduled (� " Time Fee Pd.
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Soil ,S`uitabilio Assessment for Sewage Disposal Y
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Performed By: J i�� FC1l-� f FS r P Witnessed By: ��l ✓'` Wr •S�G�n�x.� �_
LOCATION&.GENERAL INFORlYITION ;
Location Address Owner's Name �r A Y,r 4L�,4
Address �/� �®G-1:!: V
N-u,LST, /L.
Assessor's Map/Parcel: � S8 Engineer's Name pie-
NEW CONSTRUCTION REPAIR ✓ Telephone# s4e- a/3Z
Land Use Slopes(%) 40--3- Surface Stones
Distances from: Open Water Body ft .Possible Wet Area ft Drinking Water Well ""• ft '
Drainage Way ft Property Line 10 ft Other 4s— ft
SKETCH: (Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
•o �
. O
771
ti.0 m
CID v
c
�L l rr!
-Parent material(geologic) '5}4 Depth to Bedrock ----
Depth to Groundwater: Standing Water in Hole: N +'Weeping from Pit Face
Estimated Seasonal High Groundwater A
DETERMINATION FOR
YI .SEASONAY,HICH WATER TABLE
- e[hod Used. _
Depth Observed standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft..
Index Well#___•_._. Reading Date:.. Index Well level.__.__ Adj.factor_ Adj.Groundwater Level
PER:COI,t TION TEST Aatc � 1[u[e
Observation
Hole#
Time at 9' .
Depth of Perc _�� _ Time at 6"
Start Pre-soak Time @ y.% ' Time(9"-V)
End Pre-soak
Rate Min./Inch L Z
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN)
Original: Public Health Division Observation Hole Data To Be Completed on Back
Copy: Applicant
DEEP OBERVA�'IOT HQL BOG Mole<# ^
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency.° Gr el
1 A I.,S 0 Yll. �z
3z b Ls s 8
DEEP.OBSERVATIfQN HALE L.QG H.o1e># Z
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Cons' to c %Gavel
I
Z A LS la'f 2-4- Ij
-36 L�
►--t S 6
` ,:I,IE>EJ� O�SERVA�'I(JN IIOIJE I�4.� Dole# ;;
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
n Consistency.%Gravel
LIEEP OBSER`�ATION HOLE LQ;G Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes.
Consistency,° Gravel
w '
Flood Insurance Rate Map_
Above 500 year flood boundary No— Yes
Within 500 year boundary No x Yes
Within 100 year flood boundary No__y Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on -1 t V' (date)I have passed the soil evaluator examination approved by the
Department of Environmental Protanalysis ' ' 'p Protection and that the above was erformed b me consistent with
P Y
the required training, ex ertise and experience,described in 310 CMR 15.017.
Signature 'Date__ `� /7 Zcs�
OTC
ZNo. / Fee
THE COMMONWEALTH OF MASSACHLW S" Entered in computer:
Yes
i PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
1
01ppYtcattott for ]0t9;po2;a1 *pgtertt Con6tructtort Permit
Application for a Permit to Construct( )Repair(V/)Upgrade Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. `� SO s% Owner's Name,Address and Tel.No. 6 d 3-
Assessor's Map/Parcel -5-e Aw"t 1k-
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�, -1 0. ?2- aS''3v S' 2 S�U�- 3C2- 172
Type of Building:
Dwelling No.of Bedrooms_ _ Lot Size 116 l/ sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow //0 gallons per day. Calculated daily flow 'YV0 gallons.
Plan Date Number of sheets / Revision Date
Title
Size of Septic Tank /'u O U r Type of S.A.S. 3 s coo .rCfw e�w
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 0- l P7L CX-44 uz� lill-j�o Meet__
t_"
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signe o Date
Application Approved by Date
Application Disapproved or the following real s
Permit No. Date Issued
r
No. c. � � Fee
V/N_, L Entered in computer: }
THE COMMONWEALTH OF MASSACH S S��
,k�.�._ •"s.., Yes
PUBLIC HEALTH DIVISION--,TOWN OF BARNSTABLE 'MASSACHUSETTS "Y ,
Zlpprtcatton for kop ml *pgtem Congtruction Permit
Application for a Permit to Construct( . )Repair(Upgrade 4 Abandon(° +) 0 Complete System ❑Individual Components
q ] - s
Location Address or Lot No. of $� 5T Q V! Owner's Name,Address and Tel.No. 6 v3. ff-?• 131147
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
/? Ql
Type of Building: )
Dwelling No.of Bedrooms Lot Size //G 7/ sq.ft. ) Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria.( ) f
Other Fixtures !
Design Flow //O gallons per day. Calculated daily flow y�`/O gallons. 1
Plan Date Number of sheets / Revision Date \
Title
Size of Septic Tank /6-0 U Type of S.A.S. 3-5,00
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) taz C,44,t>ad LC"- .-U iv►".y-'
t rv, .�i.C/G� 4 a �F 5
'A
Date,last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
yin accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- oc"
cate"of Compliance has been is wed by this Board of Health.
Signe , . A o. 1&4. 4 e _ Date
Application Approved by _ 7 ! a Date
Application Disapproved or the following reaso}I27_ r
Permit No. ^~ Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS;
a
Certificate of Compliance '
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( )
I
Abandoned( )by
at I has constructed in accordance
with-the provisions of Title 5 and the for Disposal System Construction Permit No. `_ ted
�'- Installer Designer `
The issuance this ermit shall�not be construed as a guarantee that the sy a wil unction s designed.'
Date r7 Inspector
li' x
No. 0:�4& Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Miopogar 6pgtem Congtruction Permit
Permission is hereby gr `tte��dyyto Construct,(-/ )Repair(. U ,ade( )Aband/on(® )
System located atI �� � �! �f
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.Ix
/
Provided:Construc 'on must be/completed within three years of the date of s .e"rmit?
,�r 1
Date: �( � Approved by d � �.i
Town of Barnstable
A
y�P°Fj TOyti� Regulatory Services
t Thomas F. Geiler, Director,
x BARNSTABLE, +
9�A %MASS. 10� Public Health Division
rFD MA'S A Thomas McKean, Director
200.Main Street,-Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
1
Date: Sewage Permit# Assessor's Map\Parcel tj8-OS6
Designer: cZ- f+C �h�A� Installer:
Address: , Address:
On was issued a permit to install a
(date) (installer)
septic system at 2* SZ',` based on a design drawn by
(address)
r�/� dated 9 l Z L 0
/ (designer)
V I certify that the septic system referenced above was.installed substantially g accordin M to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local_ Regulations. Plan revision or
certified as-built by designer to follow.
(Installer's Signature) IVI
E �1p.354S9 `�
JcL
esigner s Signature) -(Affix Designers Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
QASeptic\Designer Certification Form Revised.doc
rt:
,- ACCESS COVERS MUST BE WITHIN 9' MINIMUM. INVERT ELEVATIONS : DESIGN CR I TER I A : GENERAL NOTES :
6* OF FINISH GRADE 3' MAXIMUM COVER
INVERT AT BUILDING: 99.8 DESIGN FLOW:
IO2.05 FIRST 2' TO I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION
BE LEVEL MIN 2" OF PEASTONE INVERT IN SEPTIC TANK: 99•5 4 BEDROOMS AT 1!0 G.P.D. PER
-- OR F I L TER FABRIC /NVER T OUT 'SEPTIC TANK: 99.25 BEDROOM EQUALS 440 G.P.D. OF THE SEWAGE_ DISPOSAL SYSTEM ONLY.-
4' DIAM PIP
3/4" - 1 1/2' D/A. INVERT /N DIST. BOX: 98.47
- ° DOUBLE WASHED STONE INVERT OUT DIST. BOX: 98,3 NO GARBAGE GRINDER 2. VERTICAL DATUM IS ASSUMED. FOR BENCH MARKS
9.9.8 "=� 9. 98.3 2. ' �° SET. SEE SITE PLAN.
s a GA s _ $ _4 i NVER T IN LEACH CHAMBER. 98.0
9.9�s BAFFLE-1 9 7 98.0 SEPTIC TANK REQUIRED:
3 OUTLET 3-500 GAL LEACHING CHAMBERS iADJUSTBOTTOM OF LEACH CHAMBER: 96•0 440 G.P.D. X 200X - 880 GAL. J. ALL CONSTRUCTION METHODS AND MATERIALS AND
'D W/4 ' STONE AROUND. 12.8 'r x 33.5'1 x 2'd ADJUSTED GROUND WATER: N/A MAINTENANCE OF THE SEPTIC SYSTEM SHALL
D-BOX SEPTIC TANK PROVIDED: IS00 GAL. MIN.
1500 GAL 'OBSERVED GROUND WATER: N/A
CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL
SEPTIC. TANK 6" CRUSHED STONE OR
BOTTOM OF TEST HOLE *1: 90.7 SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS.
r COMPACTED BASE DESIGN PERC RATE t 5 MIN/INCH
PROF l L � : NOT TO SCALE SOIL TEXTURAL CLASS - 1 4, ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER
EFFLUENT LOADING RATE • 0. 74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER
440 GPD / 0.74 GPD/SF - 595 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH-
STANDING H-20 WHEEL LOADS.
PROVIDED: 3-500 GAL LEACHING CHAMBERS
W/4 ' STONE AROUND. A-606 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR
606 S.F. x 0.74 - 448 G.P.D. APPROVED EQUAL.
6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED
SOIL TEST PIT DA T A ® PRECAST CONCRETE OR APPROVED POL YETHYLENE.
INDICATES �� INDICATES BOTH SHALL BF- WATERTIGHT, D-BOX SHALL BE WATER
PERCOLATION --- OBSERVED TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE
TEST GROUNDWATER OUTLET.
.CBIDH FND TPI P*13045 TP +�2
f N 88°24 '30'E 7. BEFORE CONSTRUCTION CALL 'DIG-SAFE".
/0.0I ' ` 1-888-DIG-SAFE AND THE LOCAL WATER DEPT,
srocr;ADE FENCE 40R I ZON TEXTURE COLOR fIOR I ZON TEXTURE COLOR
7 0' 101. 7 0" - -- 101. 7 FOR LOCATION OF UNDERGROUND UTILITIES.
L O I �J 7 l I i �j L OAMY I O YR A LOAMY /O YR
< mi SAND 2/2 -- SAND 2./2
8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE
671 + -.S,. F. 14` .-.........•............................. 100.5 12' •••------ ..................... . 100. 7 DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION
LOAMY IOYR n b LOAMY IOYR OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE SAND 5/8 L7 SAND 518 NS
PAVED DRIVEWAY`, .32' .......................................... 99.0 30' .................................... CONSTRUCTION 99.2 0 TRU INSPECTIONS.
P CT IONS
GARAGE C / MED l UM I O YR c / MED/UM I O YR
' 9. EXISTING CESSPOOL TO BE PUMPED DRY AND
CESSPOOL'-. `" `�, SAND 6/6 SAND 6/6 BACKF ILLED.
PATIO
v /0. EXISTING INVERT AT THE DWELLING TO BE
co n 48' RELOCATED TO THE LOCATION AND ELEVATION SHOWN.
STOCKADE_ FENCE
• O ,
O
Q c p
- O EXISTING FOUR N'
G BEDROOM DWELLING
jj 132' NO WATER _ 90.7 120' v_ NO WATER 91 . 7
40 MILL POLY
/ VAPOR BARRIER `•
DA TE: SEP TEMBER 8. 2010
' '" TP.I 6oX TEST BY: STEPHEN HAAS ,
t o m �,. �
i i, -BM. CL FRONT • gyp. ` WITNESSED BY: DAV/D STANTON3
SEE NOTE !0. STEP. EL-l02.47 ' PERC RATE: C 2 MIN/INCH
ppe pp a�
Sfi p 3 W y Al
1500 GALLON
SEPTIC TANK
p2 3-5d0 GALLON
s
LEACHING CHAAIBERS # ens , , rh
Y!_,4 4 W/4' STONE AROUNDIN
__.S 88'24 '30'W IP FNDr
e
q
A
SO UTf S' f',�' 7" S �F� T / C S YS TAM � � S / G/�/
' 24 SOUTH S TRE"ET , MAP / / 8 . PARCEL .Se
SARIVS TAR 1. E
< OS7-ERVILL S_
µ VARIANCES REQUIRED : P,�EP,4 RED F-0R
�- r , •' TITLE 5. MAXIMUM FEA S!BL E COMPLIANCE G f-1 R / V L.� 1�f-i S O N
SECTION 15.21 1: (11 M/N/MUM SETBACK DISTANCES L EGE ND
20 ' IS REQUIRED BETWEEN THE SAS AND A FOUNDATION WALL. 12 ' IS PROVIDED, r-
%Y 1` _9 / 6 COL FA �V A VENUE . EL M/HUR S T . / L 60 1 .26
AN 8 ' VARIANCE IS REQUESTED. ® CB CONCRETE BOUND
( -W WATER LINE
LOCUS ' t '`, 1 '' `' a' .-
tT.' SCALE- : / 120 SEP TEMBER / 7 . 2010
O HYDRANT
n ••-G GAS LINE
NE
EA0L_ E SUR \VEY ! NC I NC
OHW---- OVER HEAD WIRES
LIGHT POST
92.3 Ra u t e 6A
MAIN sr• i..=•'
-E--- UNDERGROUND ELECTRIC L l NE Y a r mo u t h p o r t NAA O 2_6 7 5
-T- j UNDERGROUND TELEPHONE LINE 5 O F3 3 6 2-8 1 3 2
CTV--4 UNDERGROUND CA_BLEVISION LINE �� �/ �� 5O8 � 432-5333
% +40.4 SPOT ELEVATION
1 t f i
___40-� '�,EX 1 ST I NG CONTOUR -
n __ PROPOSED CONTOUR
LOCUS M,� 1' 1• 2• 4• =JOBNO: 11-094 FIELD:CFW/EEK CALC: 5AH/CFW CHECK: CFW DRN: SA
•