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HomeMy WebLinkAbout0023 SPICE LANE - Health ° V23 Spice Lane Q . Osterville P o 0 0 165 120 , A ° . , ,a o 0 o a , . a , x - . o o s n e ° - - � — ,. - o � �� a h• ., .. r - e < ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Spice Lane Property Address Peter Friedensohn Owner Owner's Name information is required for Osteryille Ma. 02655 5/11/2010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out 314 �DD forms on the computer,use 1. Inspector: only the tab key to mo4y66r Robert Paolini cursor-do not Name of Inspector use the return key. capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 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 ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority C:) 5/11/2010 1 - Inspector's Signat Date I � y The system inspector shall submit a copy of this inspection report to the Appr wing Authority(hard of Health or DEP)within 30 days of completing this inspection. If the system isa sharedtisyste -or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall s Wit t 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. I t5ins•09/08 Title 5 Official Inspection Form:Subsurfac4Sewage al System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Spice Lane Property Address Peter Friedensohn Owner Owner's Name information is required for Osterville Ma. 02655 5/11/2010 every 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: The septic system is in porper working order at the present time. 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): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 23 Spice Lane Property Address Peter Friedensohn Owner Owner's Name information is required ror Osterville Ma. 02655 5/11/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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: ❑ 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•09/03 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Spice Lane Property Address Peter Friedensohn Owner Owner's Name information is required fcr Osterville Ma. 02655 5/11/2010 every page. City/Town 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 asses if the well water analysis, performed at a DEP certified laboratory,for coliform Y P Y � P rY. 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 cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 23 Spice Lane Property Address Peter Friedensohn Owner Owner's Name information is required for Osterville Ma. 02655 5/11/2010 every page. City/Town 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-09105 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 23 Spice Lane Property Address Peter Friedensohn Owner Owner's Name information is required for Osterville Ma. 02655 5/11/2010 every page. City/Town State Zip Code Date of Inspection a 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) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 23 Spice Lane Property Address Peter Friedensohn Owner Owner's Name information is required for Osterville Ma. 02655 5/11/2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2008:86,000 g ( y g (gpd)): 2009:109,000 Detail: 2008:236 gpd 2009:299 gpd Sump pump? ❑ Yes ® No Last date of occupancy: 5/11/2009Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Spice Lane Property Address Peter Friedensohn Owner Owner's Name information is required for Osterville Ma. 02655 5/11/2010 every page. City/Town 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: 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments pco 2 i,M 3 Spice Lane a e Property Address Peter Friedensohn Owner Owner's Name information is required for Osterville Ma. 02655 5/11/2010 every 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2211 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.system vented through the house vents. Septic Tank (locate on site plan): Depth below grade: 16"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 5" t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,^M 23 Spice Lane Property Address Peter Friedensohn Owner Owner's Name information is required for Osterville Ma. 02655 5/11/2010 every 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 27" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 23 Spice Lane M Property Address Peter Friedensohn Owner Owner's Name information is required for Osterville Ma. 02655 5/11/2010 every 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: Date Comments (condition of alarm and float switches, etc.): *Attach co of current pumping contract(required). Is co attached? Yes No i PY P P 9 copy ❑ ❑ t5ins-09/08 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 23 Spice Lane Property Address Peter Friedensohn Owner Owner's Name information is required for Osterville Ma. 02655 5/11/2010 every page. City/Town 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 D-Box not present. 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(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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/03 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 23 Spice Lane M Property Address Peter Friedensohn Owner Owner's Name information is required for Osterville Ma. 02655 5/11/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): Sandy dry soil.No signs of hydraulic failure.Both pits were dry at time of inspection.First pit stain line is up to invert.Overflow pit stain line is 50" below invert. 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 MDimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/03 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 23 Spice Lane M Property Address Peter Friedensohn Owner Owner's Name information is required for Osterville Ma. 02655 5/11/2010 every page. City/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.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 "Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ® ® zoom Out I I IN I]fl M'In A K 1CJ1 ,bY111 R. in u NR k e�k cf S ae� � r z •�Y r r ilia '. �}� ���,✓�` . f ^h I a � � <y (� Ry V a 18.5 �g s 3 3q 3�, } 20 Feet- Set Scale 1" = 20 i I Aerial Photos I MAP DISCLAIMER (`nnvrinht 9MF_9l11n Tn... of Romefohie hAA All rinhfe rocone <L . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 23 Spice Lane Property Address Peter Friedensohn Owner Owner's Name information is required for Osterville Ma. 02655 5/11/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP10.8' 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: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. N Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/03 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 23 Spice Lane M Property Address Peter Friedensohn Owner Owner's Name information is required for Osteryille Ma. 02655 5/11/2010 every 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEAL'i'H OF MA,SSACHUSETTS . EXECUTM OFFICE OF ENVI OrNM'ENTAL AFFAIRS DEPA tTMENTOF SNV1104MVNTA?1 MI CTION y tVIAP - . PARCEL ;, 12-® �- A�n TITLE 5 OFFICIAL INSPECTION FORM—.No.FOR.VOLVNT-ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART•A CERTIFICAT-10N . Property Address: 2'� ny 5 Owner's Name: Rar_hnra Knoxgi oc Owner's Address: RFMVE Date of Inspection: AUG 1 3 Z004 Name of Inspector: (please print) . Company Name; , % /1]acom�e�t .Spn Lric. TO�HEALTHDE jr TABLE; Mailing Address: Ce�z ���+.z .e, .a.ab..02632 Telephone Number: 5 O 8— 17 3 33 8 CERTIFICATION STATEMENT I certify that I have per inspected the sewage disposal system.at this address and that the.informationnported 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 roper function and maintenance o on31 C sewage a e disposal i po al sys dms.I am a DEF approved system inspector pursuant fo Section.15:340.of ( Passes -Conditionally Passes Needs Further Evaluation.by the Local Approving.Authority Fails Dater Inspector's Signaitnre: c s inspector shall submit a copy of this inspection.report-to the.Approving Authority.(Board of Health or The system p DEP)within 30 days of completing this inspection.If the system,.is.a.shaxed'sy�tem or has a design flow of 10,000 gpd or greater,the inspector and the system owner.sliallsubmit 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 w4zp- ( +0 L,f)Vef+' t h ****This•reP ort only describes conditions at the time of inspectioir and under to condindertions game of use t th ff rent at time.This inspection does not address_how the system will perform to the futu conditions of use. naee 1 Page 2 of 11 r . OFFICIAL INSPECTION;FORM—NOT:FORYOLUNTARY. ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 23 Spice Lane Osterville, Owner: Barbara Knr)wl PR Date of Inspection: R_/4.4 o4 Inspection Summary: Chltk A;BC,D or.lE/ALWAYS complete-,all of Section: A. System Passes: I have not found any information which indibates'that any of the failure criteria described in 310 CMR 15.303.or in 310 CMR 1 5.304 exist. Any failure criteria not evaluated are indicated below. Comments: l° q r IC_ S L154yY1 t� 117 ?t��('� tt1o:��',l.Y'LQa _ ®�� A� �1�,.'�`7�!`(�.`.�E.YbT' T t rAQ- B. System.Conditionalliy 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)isstructurally unsound,exhibits substantial infiltration or exfiltration.or tank failure is.imminent. System will pass inspection if existing tank is replaced with'a complying septic tank.as approved by the'Board.ef 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 pipes).are replaced. Obstruction is removed distribution box is leveled orxeplaced ND explain: The system required pumping:more than 4 times a year due to broken or obstructed pipe(s):The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT VOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPtCTI.ONTORM PART A CERTIFI.CATION'(coritinued) Property Address: 23 Sp i-Q ian6 Cis e_V 4 Owner:. uxa��--I��ta,�:-es Date of Inspection: 8.4 4.4 nd C. Further Evaluation-is Required by the Board of Health: j_ Conditions.exist which require further.evaluation..by.the Boar&ofHealth:in order.to;determine ifthe system is failing to protect publichealth, safety or the environment. 1. System will pass unless Board of Health determines:in aec'ordance with 310.CMR 15:303(1)(b)that the system is not functioning in.a manner which4will protect public health,safety and the•.environment: Cesspool or privy is within 50 feet of asurface water �J 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 SuppJier;-if any)determines:that the system is functioning in a mariner that protects the public health,safety and environment: 4' 0_ The system has a septic tailk and soil absorption system(SAS).end the SAS is within 100 feet.of a surface water supply or tributary to a.surface water.supply. The system has a.sepfic tank and SAS and the::SAS is within a Zone 1 of a public water supply. 0 The system has a septic tank and.SAS and-the SAS is withim.50 feet of a private water supply well. 1'vO The system has a septic tank and SAS and the-SAS is less than 10.0 feetbut 50 feet or niore frottl a private water supply well**. Method used to determine distance T"'0j **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliforna 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT TOR"VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 23 S p i r P T.a n P 0Q Qr_vJlj® Owner: Rarhas� e�a�es Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to.each of the.following for all inspections: Yes. No _ Backup of sewage into facility or system component due.to overloaded.of 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 _e,"' Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in-cesspool is less than 6"below invert or available volume is less than'h•.day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS;cesspool or privy is below high ground water elevation. _ . My.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion ofa cesspool or privy:is within a-Zone l of a:.public well.. Any portion of a cesspool or privy is within.50 feet of a private water supply well. Any portion of a-cesspool or-privy is less than 100 feet but greater.than 50 feet from a private water supply well with no acceptable water quality analysis. [This:system..passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from.that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are-triggered.A'copy of the analysis must be attached.to this€ornQ..] e (Yes/No)The system fails. I have determined that one or..more of.the:above failure:.criteria exist as described in 310 CNIR 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 o.f1•.0,00.0 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 _ _Zthe system is located'in a nitrogen sensitive area(Lnterim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has.failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional.office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS �LtRSURFACE'SEWAGE DISPOSAL`SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 23' Sn� c-a T.anP n c t e r sd 1 1 a„_.__ . Owner:. gar-bars Kz1owles - Date of Inspection: Check if the following have been done You must indicate"yes"or"no"arto each of the oilowing: 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-he 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 dimensions,depth of liquid,depth of sludge and depth of scum? of the baffles or tees,material of construction, Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? a The size and location of the Soil Absorption System(SAS)on the site.has been determined based on: Yes no � . . Existing information.For example,a plan at the Board of.Health. — 1Determined in the field(if any of the failure criteria related.to Part C is at issue approximation of distance is unacceptable) [310 CNIR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL WSPECTI!ON;FQW-NOT FOR VOLUNTARY ASSESSMENT'S SUBSUPFACE STWAGE DISPOSAL- SYST9WINSPEETION FORM PAItT.0 SYSTEM INFORMATION Property Address: 2'1 i Go Lan® Owner -Barlaar-a 14PAw1es Date of Inspection: _&14 4-04 , FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): :3 Number of bedrooms(actual): DESIGN::flow based 6nlI0 C1&15.203'(for example: l 10 gpd z#of bedrooms): xI 1O=33k)%?D� Number of current residents: .: IDoes•Tesidence have a garbage grinder(yes or no): f1Po Is laundry on a separate sewage.system.(yes or.no): Z [if yes separate inspection required) Laundry system inspected(yes or no):q0 Seasonal use:(yes or no): 009"1 J 3/0©0 meter readings,if available last 2 ears usage d : ' i i 9 0 o a Water m ( Y g (gP )) op 3, Sump pump(Yes or no): 1� Last date of occupancy: 2r wu& C011!IMERCIAIU TRIAL Type of estabi nt: Design floe.µ i(l ,$�on 310 CMR 15.203)% d Basis.of ftgio flow(seats/persons/sgft,etc.): ► Grease trap�present(yes or no): Industrial waste holding tank present(yes or no)IU�,_ Non-sanitary waste discharged to the Title 5 system-(yes or nolka. Water.meter readings,if available: lV, Last date of occupancy/use: . tU OTHER(describe):. GENERAL INFORMATION Pumping.Records n Source of information: 1 e\ Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:__gallons--How was quantity pumped determined? Reason for-pumping: TYPE OF SYSTEM , Q,a Septic tank,distribution box,soil absorption system - Single cesspool no Overflow cesspool. QIY» Privy %lv Shared system(yes or no)(if yes,attach previous inspection records,if any) y2e_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) M Tight tank. _Attach a.copy.of the DEP approval 60 Other(describe): Approximate age of al] components,date installed(if known)and source of information: �q�l fl Were sewage odors detected when arriving at the site(yes or no): (b'J 6 - Page 7 of l 1 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddress: 23 Spice Lane QR—F eryi 1 1 a Owner: Rarhara Knowles Date of Inspection: .44/Oil BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron )�-40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition�o oints,venting,evidence of leaka e,etc.): ' C� O SEPTIC TANK: :,/(locate on site plan) Depth below grade: Material,of construction:-�,-conerete metal, fiberglass other(expla polyethylene _ in) _ If tank ismetal list•age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: �� (�� q to'�VA ��A Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance-from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined; Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, evidence of l"ea�kage,etc.): to e)juieA GREASE TRAP:&(locate on site plan) Depth below grade: Material of construction: RAconcrete&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:.m (w Continents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet tlet invert)evidence of leakage,etc.): Ti b- 7 r Page 8 of 1 I OFFICIAL IN-S-PECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SI ,%U'-K'ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 Spice Lane " Ost.erville Owner Ria ear-a KPiwIes Date of Ibspection: 8T4a4 r TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below.grade: Material of construction: k concrete At metal ftberglasst1k polyethylene ftA other(explain): Dimensions: Capacity: h$ - .gallons Design Flow: N\ gallons/day Alarm present(yes or no):t\>,.- Alarm level: _� Alarm'n working order(yes or no): Date of last pumping: Comments(conditi n of ai.arm and float switches, etc. 1 an�h�' �� I^o�✓is� ��R flot• ' ' DISTRIBUTION BOX: (6) (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or gut of box, etc.): q •D d 5������•✓�n �ax i'L41�" �r,n�Plfl1'. PUMP CHAMBER:{'!fJ (locate on.site.plan) Pumps in working order(yes or no): Alarms in working order(yes or no):0 Comments(note condition qf pump chamber conditio of pumps and appurtenances, etc.); vl P C�1D>ujL tin- Y19J C' �r i r 8. f Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 Spice- Owner: n--'ara Knowles Date of Inspection: _=v .SKETCH OF SEWAGE DISPOSAL SYSTEM Prdvide 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. . q � oil i 10 Page 9 of 11 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 spice Lane Owner:. les Date of Inspec ton: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not locate pd explain whyr:� Type ljf leaching pits,number: P_ leaching chambers,number: Ap leaching galleries,number: ho leaching trenches,number,length: M leaching fields,number,dimensions: �\ overflow cesspool,number: `lap innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): t CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Q4. Depth of solids layer: Depth of scum layer: IVA Dimensions of cesspool. 1* Materials of construction: Indication of groundwater inflow(yes or no). Comments(note condition of soil, igns of hydrjulic failure,level of ponding,condition of vegetation,etc.): PRIVY:&(locate on site plan) Materials of con ction: } Dimensions: _ Depth of solids: T bk Conimenis(note conditi of soil,si s of hydraulic failure,level of ponding,condition of vegetation,etc.): PoWi l Q 9 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2-1 -g; ce Lance nste*-Ad11 owner: ua,-tiara KncLHzles Date of Inspection: 8 4TQ4 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet p Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you es tab ' tied the h'g grouno w ter elevation; Y194- hro ro L,D III R6 060-10 Al 13 Title i Tnerorfinn Rnrm 4/1 e/,)nnn 11 WY)_ ' ..T.,.-R.,.,_-.T••.,-�.-�,...��...,t.T,�::�-.•��.�.•rn,,,�,-�„•.�.�� I30AItU OF IIEALTII �:,•.. 'I-OWN OF __z34kr-As4a 1-e 3UIISUIIFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART. D .- CERTIFICATION Owl, ssmn�mrnn*P+errnr+w.:-r�rrr•r.--r^.r. ... T';'::t�T.lif^.�TT7'.TI'R.tTi T`iti':FT.TTT.T.T{•T,—.'.'i T'SITCR't 7T7T11R^'T ��. 0 . -TYPE OR PRINT CLEARLY— PROPERTY INSPECTED STREET ADDRESS 23 Spice Lane ASSESSORS MAP , BbQC K AND PARCEL # 165-120 OWNER' s NAME PART D - CERTIFICATION NAME OF INSPECTOR Aruce .Macallisteg COMPANY NAME Joseph P. Macomber COMPANY ADDRESS Box 66 Cemt Street Town or City state LIP COMPANY TELEPHONE ( 508 775 3338 FAX ( 508,E 790 1578 CERTIFICATION. STATEMENT I certify that I have personally .inspected the sewage disposal system at this address and that the information reported is true ,. accurate, and to as of the time of .inspection , The inspection was performed and any omple s ' recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: Systeui PASSED The inspection which I have conducted has not found any information which indicates that. -the system fails to adequately protect public health or the enviro:wment as defined in 310 CMR. 16 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this. form . System FAILED* The inspection which I have con ircted has found that the system fails t( Protect the j.--ublic health and the environment in accordance with 'title 6 , 310 CMR 15 . 303 , and as specifically noted on PART C 1rAILURE CRITERIA of this inspection form . Ins Si nature Date �® Inspector g ..-.TTJiT..��23' 7TT'�'��TT3'7����•_ ' .. copy of this certification must -be provided to the OWNER, the BUYER One where applicable ) and the BOARD OF HEALTH, * If the inspection FAILED, the owner or gperator shall upgrade ' tho system. within o'ne year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 Cr1.R 16 . 306 , partd .doc S Ce Lane, lww £d a Of Pow.ement / avw ` Cobbles oHw r R=523.09' i i ��0.39' S6975'10'E 36.29' ------ 7 / ' 4 eA 6�p # 23 �y 1 sty w/f �� Dwelling �s � ,P 0 1-10. tueam lour.}'• 6• (Rva cars) :?';;''•. w1f �.1 Shed .... REFERENCES: (�c C308 4L) ha°oa Assessors Map: r 165 S� sso 18,325*SF , Parcel: 120 LCC 30384 L : R-c ZONE . �'�ejs�9 ��sRsoo Setbacks: Front: 2O'min Side: 10 min Rear. 10'min LjH 0�Mqs„ I certify that the structures Ric:R. shown hereon conform to the LHEUREUX � ' setback requirements of the PLOT PLAN 1134:312 Zoning Bylaws of the town of Barnstable. IN BARNSTABLE bGT 0 rofes ioKVLond Surveyor to (Osterville) MASS. NOTES: DATE: 261OCT104 SCALE: 1"=30' 0 15 30 45 60 FEET .1.) The structures shown were located on the ground by conventional survey methods 22/OCT/04. PREPARED FOR: 2.) The property information shown hereon was PeterN. Friedensohn compiled from available record information and & does not represent on actual on the ground survey. Patricia T. Hopkins 3.) This plan is not for recording and is not. PREPARED BY: CapeSury to be used for construction layout or deed description purposes. 7 Porker Road Osterville MA 02655 DWG #: C478_1 g1 FIELD BY. RRL/WHK (508) 420-3994 / 420-3995fox 7 Z.> -�s JGWHbr. 11VJYr;I:'1'lU1VJ�-;;�' ►/ vicL DATE ;VILLAGE (1(Q ASSESSOR'S MAP,& LOT •INSPBCTOR SEPTIC TANK CAPACITY _ /060 4C,l/�C" LEACIiIIqG FACILITY: (type) eckA�i'1 (size) fi y� NO..OF BEDROOMS J9 � r -BUILDER OR OWNER G �� G! I�IDLti'e OWNER •MAILING ,ADDRESS t1 f�`+ •.� { � +q^ }. P � i�, 1 �'' � t � o �3i,�,, �y, � � � � LOCATION _ � l � SEWAGE PERMIT NO. P) c VILLAGE INSTA LLER'S NAME i ADDRESS e U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 5,.- jl - � 1"d W 4- �4 R A. i � I 04 Q J J THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH T /V �.� /�5, ....................:... own ......oF..........�.�'xks:ir�ble..................................................... Appliratinn for Uhipniial Workii TonDtrurfinn Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: - F ...Qste ripe,---MA....02.(i55............ .................................................................................................. Location-Address or Lot No. w ....... - ..................--...................................... ....9stervil7.e.,...HA.....Q2C5 .............. Owner Address A_&._ exyice........................................... .....Q26Ql.... Installer Address UType of Building Size Lot............................Sq. feet a Dwelling—No. of Bedrooms.....................3... ...___.___Expansion Attic ( ) Garbage Grinder ( ) p� Other—Type of Building ............................ No. of persons......3.................... Showers ( ) — Cafeteria ( ) a' Other fixtures __________________________________ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank=Liquid capacity............gallons Length_____________ _ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-----------­------- Diameter.................... Depth below inlet......._............ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ (Tq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Sand-------------- - ---------------------------------•--••-----------._...-----._._._......._........._----------------..........--•-- Descriptionof Soil--------------------------------------------•-----------------......-------•------------------------------------------------------------------------••--..;...---------- x W UNature of Repairs or Alterations—Answer when applicable______installation__of--a---1_t000 gallon pre-cast stone packed leach pit �oyerflow�................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boar health. 5111181......... Application Approved By-----•--_--- c.�1 j%j` / ----------../1-------------- Date Application Disapproved for the following reasons_________________________________________________________________________________........... ----•------ ._ -•---------------------------•-----•-----•--•------•--------------------....-----•------•--------•----------•-•-----•-••----•---•-----------------------------•-•---•---------------•------•-------••--- Date Permit No..........81. ....................................... Issued----------•---•-•--5/11/81--•--•-----•-----•. Date F�$.....$...5..00....._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH --------------- -- - Tin......OF.........�table-------------------•----.............. Appliration for Di-spuaal Workii Tomlrurfinn .erntit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: ....0265.5............. .....................................................................7............................ Location-Address or Lot No. 111.114m.leaby......... U Spice s �I� � !� �rl�. ..MA.... 65.55............... Owner - Address a _...&.... Cesspool.SQ^v3 c� ................•--•-•--...--- 128 Biaho ..Tez aced..HYa?�n .....02 9 Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms____________________ ______________________Expansion Attic ( ) Garbage Grinder ( ) a p., Other—Type of Building ............................ No. of persons.....3.................... Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------------------- W Design Flow............................................gallons per person ,per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground x water------------------------ ---------- _--- ---------� a ... ..... _ _ .. _ 0 Description of Soil.................--- -----------••. •--•--. ---•--......•------•------------- -- -•••----•-- -•-••--•.-•-•-----•......---- . •----•-- W x installation of a 1,000 gallon pre-cast U Nature of Repairs or Alteration —Answer when applicable----------------------------------------------------------------------------------------------- stone packed leach pit (overflow)•. ••-•-•...............•--.--•••----•---••-••••---•------------••-•---•---------•----•--------•-••-----.....--•-•....-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iiTL p of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boar health. �� / 5111101 Signed; Application Approved By......... ...... 5/117.] 10,�0� Application Disapproved for the following reasons:... ---�-----------------------------------------•------------------------•----.... Date----•----....• ................•--•-•---------------•--.....------•-----------------------------........--•--------...------------------•------------••--••---•---...----•••---------••--------------•----•------•---. Permit No..........81-..............•-•----------------•--•... Issued...-••-----•------5/11/8,.......Date------ Date THE COMMONWEALTH OF MASSACHUSETTS ~ BOARD OF HEALTH Town ..O F.....Bastable ........................................ ... rn............................................................................. (9rdifiratr of Bunt iffitnrr THIS IS TO CERTIFY, Tha he Individual Sewa e Dis osal System constru•ted ( r aired (X) A -- B Ce sap ool Service.................Bishops Terra--------ce, _Iyannss, MA 02�01 --------------------7---6� at..23.Spice Ln., Osterville, MA 02655 -'fthiam Leahy ...............•-----------••---------------------------------------------••-•-•------------•--------•--••------••-•-•-------•-•-----------------------•-•---••----- has been installed.in accordance with the provisions of T�TIE j of The State Sanitary i�/ll �� described in the application for Disposal Works Construction Permit No.............2-.3.�.................. da.ted-5(__--l�._-.-.--.-......__................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.....5�11/81 ---------------------- Inspector......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town..........................0 F..............Barnstable 81- z 3,C ............................. ................... ...................................... $ 5.00 No......................... FEE........................ ; Disposal Workii 05nni#r innXisrrntit s A & B Cesspool Service, 128 hops Ter. Hyannis 02601 Permission is hereby granted -- -- -- .................... •------------•-• ....... --------------- ---- -•-.._..--------------..................._. to Co t ) or Rei (X �a,n In�j,idu� ,S�}�age �io�sal SLvstem at N ` pi�ce 1n., s e e, r�� o Jm eahY ........................................................-•----•. ---------------------------------.._..----.............................. Street as shown on the application for Disposal Works Construction P it N 81 .............. Dged.....r��'1/81 � � ........................................ 5/11/81 r of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 16'-0" �. . ,• \ -i Nit D EXISTING ROOF(2x8) NEW CEILING JOIST(2XIO) Issued for: PERMIT 02/22/07 EXISTING EXTERIOR WALLS(2x4) NEW INTERIOR WALLS(2x4) • - _ i (/ 7 - BOX IN EXISTING FOUNDATION(2"RIDGIp INSULJ EXISTING CONC.SLAB W/NEW BRICK TILE OVER \ IC s _/SECTION 3 -Scale:3/8"=t'-0" EXISTING SCREEN PORCH EXISTING HOUSE - LU -� _--- -- NEW BRICK TILE _ a �` L C OVER EXIST.CONC. 1 1 Wi s ... " SLAB ELECTRIC TOE-KICr w; K HEATER LL — « ———— 2466 PKT ; u — NEW WAL w NEW BATH(HEATED SPACE)EXISTING GARAGE(UNHEATED SPACE) . .. V . ---•�--- ------- x u " ALL DOORS AND WINDOWS ARE EXISTING WITH EXCEPTION OF NEW BATH DOOR x w r t _ --- i Consultants:.. r ——— -- -- `--- _. _ �.. - - �--- -- ------- - - � NEW BRICK TILE _ ; . .. .. .. .. .L, t _ - • ..,- .r _ OVER EXIST.CONC.- _ .' SLAB - _ .. - .---- _--- AL�ICHI�Mr-ll IJ LI�VtUIL CEILING FRAMING PLAN . FLOOR PLAN 2 Scale:3/8"=r-.' t Scale:3/8==r-o" - - 1ST FLOOR PLAN ' A 1 *3 1��D�