HomeMy WebLinkAbout0065 SPICE LANE - Health 89 Spice Lane
10sterville P
65 0.03
i
�0
UPC iqu7GO
:7�GTS:�CC„t;23
t:
('1� d��M S ZDt.9 `l
.....---� �rU•,1�� --For 0
V� �
I
N �r T Y �,r y x, 't - - 1, i'' k" a * $W s>1 t et .��C "a a"r t3 g�,� t
iti}y 4 - ''.a r'` 4 >f y f '"' o C.�a 'a'..�z ii c t�".5: i t v s #` k*. ;ir'., s� ^Yi` .a..
ry:ae' -'rq N:a.+ `{.� ,, >p+- :Y J;er' r .. r: q #`1 si ' j.G,. 'r<' , ,, ,.'.S ,. 5 i f i
a:,:i v ' `'4 t' - . Z,. �s , ., S - +. &� � t W1 � s x ;�' t l,'<<.ye2+ "45,-�r ;A'k a '� +�
R � 4: a
Ll L -�,-_ u
r f q .>✓ r:f',li ���''v (. .1. .. ', .r.'�7 j r`,r'/ Orin }� ,��q .^ G$v r f}' ' -v�?v( ,:. •bl k o-ta it rf c ':,�4tt '�'.u;
r b r • ''� i iv 9 J �rS `j 11 r /'W\ ��P- Qt ..y ASS ek'4. I '' as'. n� •a + k {� i„' 9�."
'. '�! ,� _ 3 t V-A T er G' a h s 4 x� 7- "If•r S:7y,.'a t li�'-:. �i. �' , '�"� 3" �' �4
,4° Y� 3 ��44,,,,�� 1 ,, y f7 m frl: '*#• a.[ll v i'^.,. R f 6 .s" g `'a =
+ n +` .! ,1_ s a "'�' r" '4a'+i' a"t c.,i +r>~ 3 . n . , ro �.i" +.�, as °, .3 av '} "u, ,
1. ,' 4, Y r}"c -• ,c m -_ ] : +»*x�, a k- c €� c. . ,rj1° 'r a;�' ti - a ma y-z -
�s r u k a� k s
r„*r- a:ri d .7. 'y i � .°q " -i. 41 r v �> g'�' � `C, t r a -...� r A$..�, f r -[$N"1 a.
", f }i ca S, `fir `�:. �v fY ,%"" y _J�+*° i T"' 1,-,-- . ,�t- ,.x„ s r .�f c �_t�s' , t, .�, $#u.�'*". ❑,- # `;'.•. 's i. .
�_�y, F Y;'i n a ti't - s»3 3 �.,dar ...�•„r i v'+ rP c#�y ' . :{ `' , r cy. - �'#'# �• `.
4"� >�i•;+#1't f3. � a9 • ti k x k' g r .. # ° z`w cyy. + % ' -ti + �y t t,?
. :.a a' .;,,.. v' + .:+ro �, t o e-, q t°+f r `�'�` a '` ' :' �`�as k;; +-"I t;k� t' '. 0 t .T r sv to r +'f s� G:
d�
a p f1 G 7 ¢ i «,;$3 u .ry 4',' S k3. ra �,.X^s. f ` i r r'�' ` a `�:'['I. ,i $ fayx ,ti {,i "� H,f i'
a
"I It- "i- a ,.> .� 9vs i n � i :i x ef:. •� m N „ r • �' ,., r `'t'. ► a `+'� g by . . xs �'+ n ..;
,, ?`r` F e „ Z17 a• a ,iG°mac e �a .f� x :r� a,r a s � �# y a i a�jl 4av i ' x z !'.-'n.�
v c y,�.,,. a ':'.e ky `f �`� •' "A,,.' ri f - `'7'4n�o,SS 3 `# "i� w eI.e ** w,s�ka -'v., ,�rr� ,tsti. rp� `- y.1 -.,F t '+
n 5 "'.s a 'd! p _. 'k7�-" "I r ''17 ,,{{s i- [a,1P '.o �t i .,,y !'s z
�. a :•1' 4, F s .: 'G' `r' ,•'.. 6 's' {a va �.. n#�� a.rR L.'6'S {i t' i rs vo"
..A t,,, ;ai Y s : k qTr ..,{. } r,#'.% w r - ,G S w3,ha, C,z%5 1�* '1't'
-r f7'� > .h aT 't }. '"' acaa ac Vr .y,' 8 to ,•.- d'-t kVa t, Sid I
a< Y i y-,.i2� Y. fy�J Of 1', y F a�{r i i '"y}& k� 4..� 4 �a ' irz{ �', 4` .
S ' °# Yxa d am, .c'. "! - ti a I I a a [ Y 4VA I
7 n-a 'i 6d�R.� vx,+! y17 ,�' t,t t* +'`�"F` ' 't;''� f€ ?•r® ,, s .
-p. {r a t�' a`a f �' a g is a '.S, *,� 7a l,'«,rr;' ,"{> - ,.r�` ram. yiw, 'PS?s n' s m a';:.
%
* p r Qu u i a s � r .Yt ' r•� , t�, twtt t ! y t {t ^c.
$ +. O fx y 5 s. A t,t .s f +" av s '' '.}" d �y 4't
t" .4' rr•.e `.,7zL�y U -�k 4 tv ,* r - �, .z. .t�" .yy '3+` ,�' ' I "id' +, rr i' k I - I
k 'A
.at s r'�� ♦ -.4� vA _{ 'ham °g �y�'., z, w �,�41, X r t'= 3f' W_r+. a 7i +.fix. „ c H"S, v �5 - - t Si e'� -
a 9 YH#' 7x y' Lj r ¢ A Yy, S L v yy � } ? ' $ q'kin"a
•u'.v ,h. '-. c ,' 4 su'Y `E�:d° a r , ...r hY ,a S Y V n.* i ti .( .'s '- a, h
.1•-. i r �� t - s a moo` f k ,�r�� .
i.� ^. ° 'zn '� t" qz 3„ ' It .y ' .#F ;r',S+7�.x,; x 'y , F..6x r, ,k',,. •+rs a- -, i 3 A'�
;f �, t � y -x+r' _:.' F+ir «�1. � ei g�,5c '..rd �..i} L A.rt a �' ,fit -9 ` -,st• ,ram. `'„� ��"
t t -� 4#. q r t -`, - C a''k i,. ':(i}FAy i' f -Ra' 1..{y fig.a' ',.v b '4
t< a { � � ➢,+ ' T a ""cc,ti f,x,: "' a ^x+• Ar rt N .t".v T` ?"' �re t14r? 15, ;iris +i fiat. M;'•sr� J"a:r`•
+ i r•� S.I ,�. " t f�,�'' -,riq'a ter•if.I[.
:_# v�q , fi ® t, f.`,," a n,. - I '•.� 1 I :,• a� " r j+� a
x'` q : ' '!yn - d.p= , 'R" �,� '.`r '� �,� c 5# ,,^3Q�r PL4. ' .,tp r1,' i it 'K* ry„ , o v r".,}a ."' . .0 o}i
'' _t ai�� i ti '+::'. .,- �r - �`, 9 ' �� ti'3' '„ as,'�` "= V'T►f (, +'+x ' t lrf.r. 'tr.9 xr`ik" ' �' fi k'�-. � �. al� r.,'.
1.
+ f n r4€ S^ `F t ® e :<,�s ? 4 r'.„Imo, , ..�f',40IK) ,,, L .s 4L +. j %� a,„%-"
's'9' :a,i' A v' i '3- '' Z'.'r d F't•;` ? �'yk ib g}} g, > " , 'N. e.`y''" �3 A'- +'f` 3. Y
+r •a„j3 a :.,. , .E -.m # m .ya•2 t�-k' i ' r .2 h is +� + .,,3
?I= b ,. t.'; 44x 9` ��.� s' [sw.' .L" s�a`${+ r'"ra,�.rg+vf i' m vr�B! +.r'", atf v .t '2A' r-4 C `i {i,-.�,-m
tl -3 'e 9 tl $ u r e s .r t s��t t4>'r , '..+' t.+ % a y eL
--- t µ-:' f, y _ - r r p;. c• es ry-.r ,''•S ,. ''` �' m t•�a. F �,)+ -'e, * '�r...G
�, s > .:. x 4 .3`, a '+g �( rFr'4 ''' r< ri wca•_4 d r�'•`�%.:s�o'I 4x"sa � r;r� K
eY.{, }'�'t ,`3�C47*d 5 'q'°'_ "i, , f,.r+` ,.a.� r -4 t �"'tF k A '�,. "'r" 1_ r: "^' � �+c'-+, '1 :yr„rt,,��+r+�� ,t zr p. ,€' {' ;i �R 4
P r '' f to c , i �"+i ^x+ t„"n r � . 'P. tjr j" � ,a tt, r�`o � ' k*? ¢ .:
� .� � ,+ s � . � ,.+ , _' �� "'Pe as f M , ,I U.A , _'c s u ° ' l r r Y�f n - r a
' �,yb a ,f ,-v �. ..; �`�,:i,p-du ,R1.-J & ..v,$, '- .?F+ s�r .,. ^ ,4?. ' 99 ' '.,..., a'#?'a ,✓`+s �, k.,:�'
s x a *+:rt *2 '..E Sl 4�,11 r rx1.A a Ca} 't '�43' ye,S t vial a e r
�* -`�F auv y r $: a �7s t3` :F{� Gac _+{�a} 9y1fu *y.f fir} 54 t 'd� i 3 �-
,f}::.a s r �' '�'�'ra r`i. .s•r f , wtar'G t. 3 `,mot' -.. t X'1.9t"ki r : ,-,�` o- ..�, c» .,�+y„` 'A� re,I" "' g s+ '•r �c1i
✓i.. .+'�. rc t 'rJ :d .h a7 ,, a'^(" -t k r *�•�Rz `K nx s*n c' *:.. '�+4 $ -R+, n ..rS,r
n , , 1 L �..,�. 'I� x , k� r G � w ,' c z�.' -,,, e ,w ems' }t••,d
a. _- V 1 8! ; '..gi.s,.,+. - L ka.Y„`' '; "�"- t 7.. 4t� "r'n. k1 s��LY..n sw } "F',. f 1� .4
•> 'S- va, ,- 4r. a n f tk 'h y` -. aa('.�� -rd + d3 ic+" .'* .R p.
r ° k} ' <� s 4a "" { �a q y;t w �, r G y 4t*° v*�,,%' a �, f a,y y }a A C� '
*f L EL r t P ; w� €i :. -pq g C: `a�' `'y a yiet° `
..�.t y 4 Its ' �.' r 'r u. +, v ef4�,+IF °` - .a r q 3..,,g. ,t "k'- 1"may'' 'o1 pr4 u K..
. .`C,: +., te;. S t T 9x Yr �. � „a.r •-4 1 �A,.uty) J. te. " ".cr.O"��rs� "'- , , a. r� .r',y , #}..` e
�. ' t -,j,, r {•,ar K, ..�.. s �'.� d"4�',, rz« "'X �j q„ ta_ i '^a'ak `W. 3 atL b" ,3F - r g��'
'� '{ t5 a, "f Y
a
z y F _ ', ' a 's v -z �. '�. rl, :G i- y x.1 ;tT:. ,.X' - ' x -.S r �.k� a' '" - -+€"{'r -+. �' 7
"I .
, ,. rr -° *1F Jr<'"..- *'a es r Y:k y- K, . "�` a L - 4L,,,�,,,�! 4,t ff
cY .ks I.`" �a v'�v'. =3 •�..r''A
r;,r s'�i., P k,.,k -a,�. `r e # „»t.=.� �. 'C1::' r "-, ' " 5k,-' �t ,�`��}' '"' '�r a +r, r "�'. ;' t." ,;.
. - ',,d ?
.}"H. ..� r° ,v.;, a:q.a41
,,i+ va•tF- ^E'd',Y '. w: ,; ` 'F.gv"v 4# rY 6�* ,a" r °' '. y$'y'.n� d'•�Ir ..� " ° , s• .
GG +`.•�' S j . ". 't''� -.frY3 ,3i re��e•,+ L 3�' r k -"'' ", ,.y t3`r+ , .�P,. " .a,
...,. y+*. .p :: yr+t + . C'e .. *A� +" .' '% 'fir z `f6§ !'' '
ems" a.'° ._ r �rr p�
1 rb as a °a �'1 a r tNr 11
t a ~" ,try r a,4" "y tk �w f
4 ��
�,•, I ,*S-w � r +�. 3�. U"" 0 Ste''�' .�,a-q �- �t4r Gk' t4t"Y, ;f'�'.A' �' ,, � r. �r#£r�1 'r,�":
f 9 "r; ,. r� z �bv'X'sS� �,� yy' C `+3 t -:c
'°•. t t� [ .J.s i' 1 4 #><��i' ,a n '�ti.v?'�xs '>e a rF' °t"� ''y�' -.• u.�.rE�fx1 R-'I ,,a#fj,���-p��� i! t�fir,r. �.. 6 +x€t �'..
f { p °J ,^"' a�: :. a F4 ; �lFvi�.q t I. +,.-: g a S s{ty h"'er" P ,
Lf i` .1 nr3` u w 3 ter: t z t eY F Vi£ � a'j ra t d �" t4 ",•s �r v. ,�r yid .j
C -w 41 , F+' t, Y M ?�,�r'+ ',4'TA ,' Wa"3 m i• V- eKy`3 ` �tf r'K. .c usR.-ftf( ae.'} :-Dtw ,JfRzd=.Lys **a ,t3 {.:
aa� d• a Rtr
T d*[a �1>•` tee♦ f$ y f.�: `r 1 '"s ,� s"• +' Y�t'7 t�*' ,�.>, ivQJ •d '.{'' ji 'ws > x �' R- >-qC�. r.1���c. "r sri' v.t ro p'" !'L��7 F # �k V_ a.:' -vT, r ti •' K, a .,-s v[. +s , ., ,-,*#ty,$,�} 3,' e .:. 41, ri ? t'.'0'+..� -`, C r'f NK„ ' ji L ��tt F7"'r rr'$'ry x v
._ a ^t ,''' f ,. •k1 3,"IK yif .�' !k�if � rr Qd � mot, ti.TZ .!i .(
S.. o ems" r ., ���p rYs� ,_ .11` e°,�` k7" ,t 5F'�' 'a'�" ti.`.9 '""},eF' °', fa'r'"t "+'I �'r$ ,�• A� 4�y,n� a`k ' '4 '..
r �a
i } a'!:: 7 r gY' '�'._ 4 O ir:$3 'i" x" r+ r x x, i� '?;«a I _ '-
' c ` "` ;`, r� s �' P a as i�- E t '^1' r 4 ¥i :� i ,
11�
VV' ` ' . �qq A� s-' rtd 'rr `3v�� c "9t iT,ty �Y 7 `' yk� ov
,
v r _-. J. 1 yye�ss �f ,.ti+'I Yr,, 3S ...�, y�f�,�,� +*, Y '6.4 �. st .rtr. -' y�., C A ,�'y5 .
a L y ,,¢rn- ,ri':s 4i. 1L y a ,, is, + Yt€ '.y X�xv>>. ax '.4 r .:M1$y .9.' :e � 'sa�.„�.'iv w Y 9�` tF�p y' Y a F.
* , . n r k ;� r. rn Ey § "K * .tj*{ s i i, , .mot r rg c� f� 7 t , t n s . :s. r r`ts
s x`r '7 v Y a k •t ""'?'}i' r'; 7 11.., -. , a a '' ,.! ':rF>�'v`i.•*:, -µv "i Z ' �{ p R_''�;g °''"• .•'• s a -s + '' }..
4~s r +ar {c.�, k_ a, .ems �g*'7` i Fe t'� }t d �'" s- "� �-, 'r. ;,t,. g r ^c! .. 11 R 5 RS nY `;{'a a+` t`� �..r
+ u & "* 'd.P f - ` �r a i +y� .�.'':e c r ,:... 3 f. ,► ,+sC p- r P ,4°'�i+2. '•u "LL
`+k- w.
r* " t„w� r't .- _ t, sa; a 3¢ k�m' s j_ > r a, , s y .�,
•: �"' .,+. },era " e d# h: •! .��i� t?t-s�r ck -a .+[,s, s;a ,r t 1"+ "�•`` '"; �;;u 2:" a'" 'aa
�' :i s ;t�'%e`,V +wt° f%* �'C v:r �I k r���`�#�",�z �:i � a'i r� �*.w� #�:�+y+����+,^ jt a�� � �G..7 �j �"���s>rz
tf; ..=?'S, .a M h• c �".,.� ' ,�.,.t .riy"+, ,..r r+,• •. '� ., ;yr5'; * u. �r .;. ai^F,+. t ... ,,.-<n _t
y.:# . . ..yct3,, f 't* +rJr'�` }.ar *r'f `:.'"�" `cc. "'r$;`- {-� '"# ' ">, ,u.,i a. b ?'_rs �. "e 9�q..,, '�k. t7;7 I t.J �Gf�*� .g�' 3-r'�*Ex,S�'.
)'3C at .- ,3$ _ ,Y, t9,k E r^r. t''+t,,, �§ s�'`a"� t g 4 .. ..;t' L �`v7 '' o" a '^x�.» b '' ;h,'^ 4 ,...Fs• '� Y�.:..,.,s•Yi
k €s .•+.+, 1a 'r:. '{ = Y4 + -tea a4
1� fr a L` fri t s y R a r a .; a , �« k." s+
rl.'a`_ 'm- SI..''✓• ; -, x' b' -• - '.4 7"t s,;r�a '% n y's' 'S" c. 'yk�•�"'.a f a. A ',4. aA 4 +...r .._...
x4 s{r As '4,1 r,�,- yr' of s a ,v $ t a [d � a t t r �
"' ..fa'-" _ ti�`�;'$"s-- ,t a..�7y K �S i i i��" r ? .; rov r,'"",.'"'b vrt.4 q 3` _ 'rta +t,I S' r b is ,t err"
s r' " y • ,�.4 ,`w6 y ". i c- -�,t, _ .r f+d r` t 3»+.it tr*
{' q. t r f�f,N'" A Tt su.+' z� '4 �I ,,. f �'�< a sv:i s ., .3 "',. , 3';�t
' F ,ram '4 ♦ s i�j t Z . e :t 1 �' 3 't a: K a' t ,, ;s, ,
1. ,* ;# qr t s. 4 T r .
+ ; If is 7v �"' x4 Ts{" 5'3.•"ie r•r L+ ,y1� . �' .a - d !� -' y '' Y i'..�,t+"`,
r ,f y F+ „'3 .*' ..Y QF t .a. 11
.I I Y r.. ,�. Ij. y ', ; y �4r k;N° i S
�,�..f3 - 2 i 'rrn- = •+\' .k' fa t� s >.li + > tl, +" ,: yank. Ii �." k•i`A
3 ;,'jt a ` a^ `�.� �. t`v w.rr} 'v ,� - # "�- �` V,. x of.- (f ;ai •`w �' •k�' .ya T. xy,. _ t:
11 y�+ a a,- ' r ' . r+ , Oaf ',; % L �< f''anP 4, fia f It t f -
7'A ,, ai. r S :: 4'?t , +r, x i°' t', t k�-x .- a �.s +4 at T uy.: Sr. s Ste` 4 g kf 5 .
s l ' C 1. .fig y a '1 _0. 3. t ::.r G +
. wi J,.. @ ,• h3 7 g,d* ?} $ „�' - f F ,`�;n 3 , 'S I �t, , �..� .+,,,- �•r •- � 1,4
11
e r..� q. A '.f 7 65 H 'r7` J ' t4 q�„ � .:� do. t r.a
A ��+ b 7 J T ii'zi w•,. u- ..ty',a .a ,.,. N { ;p, .".'7''A � ! 4 ,�',. yya,i. r'k` " I tlt°"^ .7. *c w, r'
s '.♦\z' - } .i., ti � ,-,6 I , + " w • r r 4% az 9 t , t, 'r +
ry,• r a 1x t .f a: .tc . a' Rq L.04, „, n .�.r .ta '� , 4 1 ��� �� � { - .�� � �'�
4 a, -tea 4 d �y j j r 4 f' 0^ � :' c�fi',l ! pp .' a S a x`!4' 3,`� ;, t f'4�', I
I "I
44, e .,L, 'i i'. '- t^s.. y. L , r s*4ey�` b .4:., s `.. µ 3 r�k'}`.
Commonwealth of Massachusetts 1&6- 00(`
Title 5 Official Inspection Form
Fi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _
89 Spice In t
Property Address .
Tamir Realty _
Owner Owner's Name -
information is zr
required for every Osteryille Ma. 02655 3-10-20
page. Cityfrown State Zip Code .Date of Inspection t
t R•.I
try
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. Inspector Information
on the computer,
use only the tab Michael Sears _
key to move your Name of Inspector
cursor-do not Robert B Our Co INC. _
use the return Company Name
key.
363 Whites Path
rQ Company Address
South Yarmouth Ma 02664
City/Town State Zip Code
508-477-8877 S114430
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
````��� N OF I�qS
2. El Conditionally Passes \�.�`ya`�• ""'
4 MICHAEL 'yN
3. ❑ Needs Further Evaluation by the Local Approving Authority a o; SEARS
*: No.SI14430' co z
c
4. ❑ Fails o '
l�l +- _ _ 3-10-20 _
Inspector's Sign re Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall.submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of`use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
lg Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 89 Spice In
Property Address
Tamir Realty
Owner Owner's Name
information is Osterville Ma. 02655 3-10-20
required for every _ _ _
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) 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):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 Spice In
Property Address
Tamir Realty `
Owner Owner's Name
information is Osterville Ma. 02655 3-10-20
required for every _
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.)_
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR -
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
^i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Spice In
V
Property Address
Tamir Realty
Owner Owner's Name
information is required for every Osterville Ma. 02655 _ 3-10-20
page. City/Town State. Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no.other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other.
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
�� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments.
�' .;, •� 89 Spice In
Property Address
Tamir Realty
Owner Owner's Name
information is Osterville Ma. 02655 3-10-20
required for every _ _
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No.
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c� Commonwealth of Massachusetts
l Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
V
89 Spice In
Property Address
Tamir,Realty
Owner Owner's Name
information is Osterville Ma. 02655 3-10-20'
required for every _ .
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) .
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR_ 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A) t
® ❑ 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 18
c `y Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Spice In
V-
Property Address
Tamir Realty
Owner Owner's Name
information is required for every Osterville _ Ma. 02655 3-10-20
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4—
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x##of bedrooms): 440
Description:
Number of current residents: 0 —
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage 2018-181000 gal
g ( y g (gpd)) 2019-188000 gal
Detail:
Sump pump?
❑ Yes ® No
Last date of occupancy: NA
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
!% 89 Spice In
v-
Property Address
Tamir Realty
Owner Owner's Name
information is Osterville Ma. 02655 3-10-20
required for every — --
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gPd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: -
Last date of occupancy/use: Date -- -
Other(describe below):
3. Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped:. gallons
How was quantity pumped determined? — --
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
.I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r-
89 Spice In
Property Address
Tamir Realty
Owner Owner's Name
information is Osterville Ma. 02655 3-10-20
required for every -- - -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.j
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 44 --
+ 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.):
t5insp.doc-rev.7/26/201a Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
1; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Spice In
V -
Property Address
Tamir Realty
Owner Owner's Name
information is Osterville Ma. 02655 3-10-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 34"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: 1500 gal
-
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle
2711
Scum thickness 2„
811
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 16''
How were dimensions determined? sludge gudge, tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1500 dal Poly Tank inlet tee, outlet tee, inlet cover at 3" below grade, outlet cover at 34" below grade
•t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 Spice In
Property Address
Tamir Realty
Owner Owner's Name
information is required for every Osterville Ma. 02655 3-10-20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. 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
p
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: -
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: — -
Capacity: gallons
Design Flow: gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
cam !% 89 Spice In
Property Address
Tamir Realty _
Owner Owner's Name
information is Osterville Ma. 02655 3-10-20
required for every --
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)_
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: - Alarm in working order: ❑ Yes '❑ No
Date of last pumping: Date °
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert - --
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.):
D Box is 16x16 with 3 outlets, cover at 28 below grade
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
c� Commonwealth of Massachusetts
- Title 5 Official Inspection Form
`b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v% 89 Spice In
Property Address
Tamir Realty
Owner Owner's Name
information is Osterville Ma. 02655 3-10-20
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 7
infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number: —
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
FIB Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,• 89 Spice In
Property Address
Tamir Realty
Owner Owner's Name
information is required for every Osterville _Ma. 02655 3-10-20
--^-------.— .- -- ----
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS is 7 infiltrators, clear and dry, no sign of failure —
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert —
Depth of solids layer —
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding; condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
lo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
........... 89 Spice In
u-
Property Address
Tamir Realty _
Owner Owner's Name
information is Osterville Ma. 02655 3-10-20
required for every —_
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
r •
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
'= Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
a,
89 Spice In
Property Address
Tamir Realty
Owner Owner's Name
information is Osterville Ma. 02655 3-10-20
required for every - —.._ .__.._.
J page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A
00
a ►
. •q 1 -�13 g i -�� '
3- 3'4 3-6)
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
` Subsurface Sewage Disposal System Form Not for Voluntary Assessments
89 Spice In
u Property Address
Tamir Realty_
Owner Owner's Name
information is Osterville Ma. 02655 3-10-20
required for every - --
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 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:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
bottem of leacning at 4' below grade Hand agured to 10' no water
`. Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7126I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
c A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
............. L% 89 Spice In
u
Property Address
Tamir Realty
Owner Owner's Name
information is Osterville Ma. 02655 3-10-20
required for every -- ---- --- --
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section:
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked '
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist)completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 18 of 18
I
1
I� Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 '
GM s 89 SPICE LN
Property Address
RKN INC
V
Owner Owner's Name
information is
required for OSTERVILLE MA 6-25-16
every page. City/Town State Zip Code Date of Inspection m
Inspection results must be submitted on this form. Inspection forms may not be altered lin an
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information'
forms on the , 7
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. D.A.BROWN INC
Company Name
P.O. BOX 145
Company Address
CENTERVILLE MA 02632
'�f01 Cityrrown State Zip Code
508-420-4534 S14297
Telephone Number License Number
B. Certification
I 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 1.5.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6-25-16
Inspec,pAs Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority. '
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will.perform in the future under
the same or different conditions of use.
&ePag.
of/17t5ins•3113 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal Sy
r
i
I
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 89 SPICE LN
Property Address
RKN INC
Owner Owner's Name
information is required for OSTERVILLE MA 6-25-16
every page. Citylrown 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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
POLY TANK INLET HAS METAL COVER AND RISER, D-BOX HAS 1 RISER. NO INSPECTION
PORTS WERE FOUND ON S.A.S. FUTURE PERFORMANCE UNDER THE SAME OR
INCREASED USE CAN NOT BE DETERMINED FROM THIS REPORT.
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):
i
I
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
1
.1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 SPICE LN
Property Address
RKN INC
Owner Owner's Name
information is required for OSTERVILLE MA 6-25-16
every 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 (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). T4,
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
i
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 89 SPICE LN
Property Address
RKN INC
Owner Owner's Name
information is required for OSTERVILLE MA 6-25-16
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 passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
El
® 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
El ® 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 Y2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 17 j
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 SPICE LN
Property Address
RKN INC
Owner Owner's Name
information is required for OSTERVILLE MA 6-25-16
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface.water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner.or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 or 17
I
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 89 SPICE LN
Property Address
RKN INC
Owner Owner's Name
information is required for OSTERVILLE MA 6-25-16
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 89 SPICE LN
Property Address
RKN INC
Owner Owner's Name
information is required for OSTERVILLE MA 6-25-16
every page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
ACCORDING TO AS-BUILT CARD SYSTEM,CONSISTS OF A 1500 GALLON POLY TANK ,D-
BOX,AND A 4 BEDROOM LEACHING SYSTEM.
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes El No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
2014-----273 2015----297 GPD SYSTEM NOT DESIGNED FOR GARBAGE DISPOSAL
Sump pump? ❑ Yes ❑ No
Last date of occupancy: CURRENTLY
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203): Gallons per d
P Y�9p )
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 89 SPICE LN
Property Address
RKN INC
Owner Owner's Name
information is required for OSTERVILLE MA 6-25-16
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: CURRENTLY OCCUPIED
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):
1
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 89 SPICE LN
Property Address
RKN INC
Owner Owner's Name
information is required for OSTERVILLE MA 6-25-16
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
8-5-04 PER AS-BUILT
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.):
Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ® polyethylene ❑ other(explain)
POLY TANK
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1500 GALLON PER AS-BUILT
Dimensions:
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 SPICE LN
Property Address
RKN INC
Owner Owner's Name
information is required for OSTERVILLE MA 6-25-16
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
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
RECOMMEND PUMPING AT TIME OF TRANSFER AND EVERY 2-3 YRS THERE AFTER
DEPENDING ON USAGE.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
89 SPICE LN
Property Address
RKN INC
Owner Owner's Name
information is required for OSTERVILLE MA 6-25-16
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: . gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
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 89 SPICE LN
Property Address
RKN INC
Owner Owner's Name
information is required for OSTERVILLE MA 6-25-16
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
BOX LEVEL WITH 1 RISER AND SPEED LEVELS IN PLACE NO SIGNS OF FAILURE OR SOLID
CARRY OVER.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
NO OBSERVATION PORTS FOUND
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
89 SPICE LN
Property Address
RKN INC
Owner Owner's Name
information is required for OSTERVILLE MA 6-25-16
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
7
® , leaching chambers number: INFILTRATORS
❑ 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.):
NO OBSERVATION PORTS FOUND EXACT LEVEL OF PONDING CAN NOT BE DETERMINED.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
° 89 SPICE LN
�M
Property Address
RKN INC
Owner Owner's Name
information is required for OSTERVILLE MA 6-25-16
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 89 SPICE LN
Property Address
RKN INC
Owner Owner's Name
information is required for OSTERVILLE MA 6-25-16
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 89 SPICE LN
Property Address
RKN INC
Owner Owner's Name
information is required for OSTERVILLE MA 6-25-16
every page. Cityrrown 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: 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:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
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
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 89 SPICE LN
Property Address
RKN INC
Owner Owner's Name
information is required for OSTERVILLE MA 6-25-16
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
E System Information—Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
._,, Assessing As-Built Cards Page 1 of 2
' TOWN OFBARNSTABLE
LOCATION cC.P�\.(�s� SEWAGE N �� A
VILLAGE DSO ASSESSOR'S MAP&LOT 41 QQ
hJLv i�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPAC1Ty ,SQa4t i�
LEACHING FACILITY:(type) 1i(I ,i.�L (siu) e
LL �T'c NO.OF BEDROOMS _
G�J BUILDER OR OWNER J
PERMITDATE: it COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
L
Ve c k- t
r 6
cl If
0
al,
hq://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=165005&seq=1 7/8/2016
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
l Permit# �0 O) 8
Map l Parcel
l / aOo� 3 g' L Date Issued
's o
Health Divisiokii—i) c?�—
Conservation Division / . � /D/l� ' Application Fee
l
Tax Collector y 5 (/
Permit Fee
l Q
Treasurer _
Planning Dept. EXISTING SEPTIC SYSTEM
Date Definitive Plan Approved by Planning Board LIMITED TO_'�_#OF BEDROOMS
Historic-OKH Preservation/Hyannis
Project Street Address
Village n CIS I �RV j�- &
Owner Address 5Y to 64W 00 W
Telephone
Permit Request
Square feet: 1 st floor: existing 666. proposed d 2nd floor: existing 0 proposed Total new tl
Zoning District Flood Plain Groundwater Overlay
Project Valuation D UU(1 Construction Type
Lot Size j Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family V' Two Family ❑ Multi-Family(#units)
Age of Existing Structure SS - Historic House: Q Yes _ M l�o _ On Old King's Highway: ❑Yes W-fd'o
Basement Type: @Full ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft)
Number of Baths: Full: existing new _ Half:existing new
Number of Bedrooms: existing_ new
Total Room Count(not including baths):existing new First Floor Room Count A
Heat Type and Fuel: V_G as ❑Oil ❑ Electric ❑Other
Central Air: 2(Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes W440
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:Cl existing ❑new size
Attached garage:V"existing ❑new size Shed:❑existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes dNo If yes,site plan review#
Current Use Qmacbval Proposed Use
BUILDER INFORMATION
Name S �U � Telephone Number
Address A-000 STD License# OLIO q TV
CSCUll-LC, tA1 1 Home Improvement Contractor# I a I u
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
No. � FEE A
COMMONWEALTH OF MASSACHUSETTS
Board of Health, D.0<I MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair><Upgrade( ) Abandon( ) - XtComplete System ❑Individual Components
Location 89 Owner's Name
Map/Parcel# tJ^ ,!S7 Address7v
Lot# T$ 10 Telephone#
Installer's Name V Designer's Name
Address CPS ^� Address x �'. -C IAA
Telephone# S axo
- Telephone# 3 _
Type of Buildings\C'IC�n't1//CJ�` Lot Size 14, 256 sq.ft.
Dwelling-No.of Bedrooms ��C"F P (ate, Garbage grinder (Ivf/$
Other-Type of Building � No.of persons E_Showers (LYCafeteria
Other Fixtures 4'
Design Flow(min.required) vsa& gpd Calculated design flow 4-40 Design flow provided
gpd
Plan: Date .�i �Qt Number of sheets Revision Date
Title „ �tLr G� � °}i C �� L D�.tt AAA it
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator ate of Evaluation t
DESCRIPTION OF REPAIRS OR ALTERATIONS CJ�.
The undersigned agrees t the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furthe o not t ce di Ae m operation until a Certificate of CompfiancyT been issued by the Board of Health.
Sign Date i fQ
Inspections
.,.....�Lii-•+v�"•!�r'�,.--�'"'�.`„���."'�.,,�',1.°""i"�ivi"'1�'d-b•,f'�yt�.n}...�"'`�•.r—!�'"�"�,,,�-+tii`"'rycs�-.ra.,.,��'t'''�r.as...�.�•.�'�'?`^.1.-vr' -.'wJ', _.
No. FEE
C®MMONWEA]LT14 `®F MASSAC14USEITS
"4 Board of Health, c�S ��e MA.
APPLICATION-FOR DISPOSAL SYSHM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( Abandon( - .�h Complete System ❑Individual Components
Location 9 Sp!C N , QS't 'Vt„e Owner's Name
Map/Parcel# '(DIG 06J Address fz"€
Lot# 10 Telephone#
Installer's Name , c� � C 't`i�C�C Designer's Name - S `SJ
� v�UC�
Address 3 Tn!OO, S\• crmoJ� SIP Address .O.�dx Ga C • Q I0-)O&�(i (14R
Telephone# ~ r�C�g 531(� Telephone# 5'3g — I-g66
A Type of Building , �RS� C>�Q\_ Lot Size 'T 1 sq.ft.
Dwelling No.of Bed,Fooms E'' ` ��C�ee C J� Garbage grinder ( fR
Other-Type of Building t�l�;cr�� No.of persons -;:� Shoiwers ( Cafeteria t') y
Other`'Fixtures LGu�• `�? k� �'C Qv-) rJln�1 V06tA-
}
Design Flow(min.require`'d)_�''� gpd Cialculated design flow 44-40 Design flow provided `.��� gpd
Plan: Date 1 a r d;�'- N,umber of sheets le, Revision Date
1
Title
i Description of Soil(s)— "
Soil Evaluator Form No. Name of Soil Evaluator V-S Sf4AYDa'te of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to' tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furth�agrees to not t ®place e , em in operation until a Certificate of Compliance has been issued by the Board of Health.
t
Sig B Date
Ir
Inspections
"t"3sxs.cFs�,L4•.:.•�:'#.,n=..�:�`e ".,>.^',:a::��.�.��:�:;,. � <-.a M,.,,,._..._ _-+ ,_.... __._ _ _ . i,.... - _,�
No. 0/)t — W FEE I do
COMMONWEA 14 OF MASSACIIUSETTS
Board of Health, `nO, N5T'G1161� , MA.
CERTIFICATE Of COMPLIA CE
Or
Description of.Work: '❑Indivi ual Component(s) .Complete System
The undersigned here1b�certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded (✓<Abandoned ( )
by: ObE= See lLe �,C t!v
at as
has been installed irrn��accordance with the pro 'sion/s�f 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
applicatio s n nNo. aF U0 N"3a?dated �/.`�U 7 Approved De Flow 3S0 (gpd)
Installer"'!:)✓ �� �
Designer: .�>' ��`� Inspector: A;✓ �' J• Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. ✓l✓ / FEE
COMMONWEA'�T14 OF MASSACHUSETTS
Board of Health, Gv�n�, MA.
DISPOSAL SYSTEM,CONSTRUCTION PERMIT'
Permission is hereby granted to; Construct( ) Repair( ) Upgrade�Aba don( ) an individual sewage disposal system
at as -
'� U� ��t C�.- ' `-' �{�1� --as-described in the application for
ti
Disposal System Construction Permit No. dated �----.
Provided: Construction shall be completed within three years of the da e`t of thit--am'•t 1 loc ' conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date C1 t .- and of He(lth A
TOWN OF BARNSTABLE r;
LOCATION � ' �
SEWAGE—#
VII,LAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO..
SEPTIC TANK CAPACITY \0z
LEACHING FACILITY: (type) •� v�-�,a L (size) � �n
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 3 COMPLIANCE DATE:
• Separation Distance Between the
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
i
A ! d L13
11 I . U n A r�, 01,
ISE Town of Barnstable
Regulatory Services
s Thomas F. Geiler, Director
,a Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis, MA 02601
Office: 508-862-4644
Fax: 508-790-6304
Installer & Designer Certification Forth
Date:
Designer: Y krmMgo�a\ Installer: W.
Address: ,� c,u 1�r� Address:
On � was issued a permit to install a
(date) (installer)
septic system at_P 1 �'i�2 bo Q S�e1111�e� based on a design drawn by
(address)
dated 51 t7
designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
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.
0 OF
(Installer's Signature) CI�RNIEN
E.
SHAY N
No. 1181
a_r2
(Designer's ignature) (Affix De I SAS Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH[ DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THTS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC ]HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
f
DATE;_ ----- ---
PROPERTY ADDRESS:_;.__—___
89 Spice Lane
------------------------
Osterville, Ma. 02655
On the above date, I Inspected the septic system at the above address.
This system conslsts of the following;
1 . 2-6X8 Cesspools
Based on my inspectlon, I certify the following oondltlona;
2. This is not a title five septic system. / !� O O
3. This is a sewage system. Two cesspools in series. Ca J
4 . Waste water is 3 ' 6 ' below the invert pipe.
5. . The sewage system is in proper working order
at the present time. e system is
34 years old but has used seasonallyy
SIGNATURE;
Company:J0e•.ph_P _ Ha combor_b Son , 'Inc .
Address ;_ Box_66—
__CentervilleL Ha ,_02632=0066
Phone:___ _______
� r
THIS CERTIFICATION DOES NOT CONSTITUTE_ A GUARANTY OR WARRANTY
J6SEPH P. MACOMBER & SON, INC.
Tsnks•091spoois•Loachf1oids
Pumpod 9, Installod
Town Sswor Conneotlons
P,O, Box 6775•JJ38erY1114, A 02632-0066
RECEIVED
A U G 3 0 2000
TOWN OF BARNSTABLE
HEALTH DEPT.
I
COMMONWEALTH OF MASSACHUSETTS y.
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292.6600
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART A
CIERTIACATION
Property Ate,.,,:89 Spice Lane Nam.of Ow..,Maureen Yamin
Osterville Address of Owrwe:
Date of irsspecdw: 8/2 4/0 OJ
N amov of y,a �o per: (please Pr4rq o s e p h P. Macomber Jr.
I am a DEP approved sysrtwn lrtspector pursuant to Sectioet 16.340 of This 6(310 CMR 15.000)
Company Nart»: Joseph P. Macomber & Son Inc.
M,&VAd&*,s: ET0X
��333ervi e M 632-0066
Ta�sons Number:5U
CZRTlACAT10N STATEMENT
I cerbty 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 Inspection. The Inspection was performed based on my training and experience In•the proper function and
maintenance of on-sits sewage disposal systems. The system:
ZPasses
_ Conditionally Passes
_ Needs Further Ev ustion By the Local Approving Authority
_ Falls
Inspector's Signanin: ` / /tIon"report
Dieu:
The System Inspec shall submit a copy of this Insp to the Approving Authority (Board of Health or DEP)wttNn thirty (30) days of
completing this Inspection. It the system Is a shared system or has a design flow of 10,000 gpd or greater,the Inspector and the system owner
fiall submit the report to the appropriate regional office of the Department cKnvironmenttd i rotectlon. The original should be sent to-eve
system owner and copies sent to the buyer, If applicable, and the approving authority,
NOTES AND COh1MENTS
•
revised 9/2/98 Page IofII
Printed on Recycled Pips
SU&SURFACt SEWAO[D13P03.AL SYSTEW 1N3PECn0N FORJd
PART A
CFRT1F;CATWN (contirojo4)
PropeMAddraast 89 Spice Lane, Osterville
°"^w Maureen Yamin
Dorta or k►apoc;Oon: 8/2 4/0 0
NSPECMN IUMMARY: CNN--k At B, C, a D',
A. SYSTEJ.t PASS
W? I have not found any Information wNch Mcates that any of the Wurs concHons dsscr{bod In 310 CMR 14.303 sxlit. Any tow
criteria not ovaluatod are Indicated below,
CO Wr<.DM:
B. SYSTEM CONDMONJt.1J-Y PASSES:
4)6 One or more system compononts oa dosoribod In the 'ConditforW Pao'sootfon need to be replaood a rop&Uod. The system, upc
complotion of the replacement w ropalr, u approved by the Sowd of Hoakh, wW peas.
tndcate yes, no, or not datermined(Y. N, w NO). Dsseribe bails of dotwnJnadon In all Instanoes, If 'not dotormined% oxalatn why not.
The septic tank Is metal, unless the owner w oporator has provided the system Uwpwor with a copy of a Cer"c.&%* or
Compliance (anoched) Indlcadng that the tank wu In#UUed within twenty(20)you#prior to the data of tree tnapecvon:
the septic tank, whether or not metal, Is crooked, strveturally unsound, shows wb#tantiaJ{rtWation of oxAlvadon, oe to
)allure U Imminent, The system will pass InapoctJon if the existing septic tank Is replaced with a con%oy(ng septic rant a
approved by the Board of Health.
'Sewage backup or breakout or high static water level observed In the distribution box Is due to broken w obetrucud pipe
or due to a broken, settled or uneven dletributfon box. The system will pass Inapsotfon If(whh approval of the sous of
Health),
broken pipe(#) we replaced
obstruction Is removed
distribudon box Is levelled w replaced
• .The syttom required p%nm*gmwm ttwt'fourlfmos v"ardus to broKrnw obstroctod plpe(s). The oyetsm ww-pwx--
Inspection If(with approval of the hoard of Hosith): -
broken plpo(s) are replaced
obstruction Is removed
revised 9/2/98 Pap 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (corn& ►ed)
properly Address: 89 Spice Lane, Osterville
Owrw: Maureen Yamin
8/2 4/0 0
C. FURTHER EVALUATION IS RECUIRED BY THE BOARD OF HEALTH:
Al()i _ Conditions exist which require further evaluation by the Board of Health In order to determine If the system Is flailing to protest the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETIERMINES W ACCORDANCE WITH 310 CUR 16.303(1)(b)THAT THE SYSTEM
IS NOT R1NCnONWO IN A MANNER WHICH.YYILL.PAQjECT THE PUBUC HEALTI•tAND&AFETY AAiD THE E)C1aBO i19i*L.
Cesspool or privy Is within 60 feet of surface water
Cesspool or privy Is within 60 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM Will FAIL UNLESS THE BOARD OF HEALTH(AND PUBUC WATER SUPPLIER,IF ANY)DFT7=RMOU3 THAT THE SYSTIEW IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBUC HEALTH AND SAFETY AND THE ENVIRONIMENT:
The system has a septic tank and soil absorption system(SAS) and the SAS Is within 100 feat of a surface water supply or
tributary to a surface weta( supply.
/ff The system has a septic tank and soil absorption system and the SAS le within a Zone I of a rival water supply well•
The system has a septic tank and loll absorption system and the SAS Is within 60 lest o} a private water supply waU.
The system has a septic tank and soil absorption system and the SAS la less than 100 feet but 60 feet or more horn a
private water supply well, unless a well water analysis for collform bacteria and volatile organic compounds Indlcatas tt+at tAe
wall is free hom pollutJon from that facility and the presence of emonlad Ntrogen and
not valid)Ntrate nlvogen Is equal to a less
than 5 ppm. Method used to determine distance (a?pro
3) OTHER
Ll The sewage s y stem co 6 'X8 ' block
cesspoois.The ce
revised 9/2/98
Page 3o(11
SUBSURFACE SEWAGE DISPOSAL SYSTBA WSPECTION FORM �
PART A
CERTIFICATION (contirwod)
P.op«ty Ad&*": 89 Spice Lane, Osterville
Ownw: Maureen Yamin
Date of vapeedon: 8/2 4/0 0
D. SYSTEM FAILS:
You must Indicate either 'Yes' or 'No' to each of the following:
have determined that one or more of the following failure condidons exist as described In 310 CMR 16.303. The basis for tNs
determination Is Identified below. The Board of Health should be contacted to detarmine what will be necessary to correct the failu
Yes
N / s
ggod• or'cs0 . ---
Backup of towage Irno focNl►o•eT►t+Rcornponetdae�toanoveiodorveSA 01
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overfoadod or dogged SAS or
cesspool.
Ststic liquid level In the distribution box above outlet Invert duo to an overloaded of clogged SAS or cesspool.
Liquid depth In cesspool Is less than 6" below Invert or available volume is less than 112 day flow.
Required pumping more than 4 times In the last year YM due to clogged or obstructed pipe(s).
Number of times pumped,;Q •
Any portion of the Soil Absorption System, cesspool or privy Is below the high groundwater elevation.
Any portion of a cesspool or privy Is within 100 feet of a surface water supply or tributary to a surface wet*( eupplY.
4/ Any portion of a cesspool or privy Is•wlthin a Zone I of a public well.
Any portion of a cesspool or privy Is within 60 feet of a private water supply well.
Any portion of a cesspool or privy Is less then 100 feet but greater than 60 feet from a private water wpply weU with n
ity analysis. If the well has been analyzed to be acceptable, attach copy of wall water analysis to
acceptable water qual
colllorm bacteria, volatile organio•compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
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:
j The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system Is a significant"vest to
health and safety and the environment because one or more of the following conditions exist:
Yes No /
t/ the system Is within 400 feet of a surface drinking water Supply
or �oaourtaoo•d4�++ier"wp1Y.... ._ _— ..
the system•IF•witkin 200 feet of Nut Y
the system Is located In a nitrogen sensitive area(interlm Wellhead Protection Area:IWPA) or a mappod Zane II of a p,
water supply well)
The owner or opsrator of any such system shall upgrade the system In accordance with 310 CMR 16.304(2). Please consult the local ro{
office of the Department for further Inforpstion.
Peer 1 of 11
revised 9/2/98
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,
PART i ,
CHECKLIST
PropenyAd&*": 89 Spice Lane, Osterville
own«: Maureen Yamin
Data of lrupecdon: 8/2 4/0 0
Check If the following have been done: You must Indicate either 'Yes' or 'No' as to each of the following:
Yes No i
1/ Pumping Information was provided by the owner, occupant, or Board of Health.
None of the systemtorr*o,aants haw&Jaaan par►p0d4*Jaaatdw0•w6ak44a+d4W-VY#tam haab64a9QC41I ssgea00011W fi
rates during that period. Large volumes of water have not been Introduced Into the system recently or as pan of true
Inspection.
f� As built plans have been obtained and examined. Note If they are not available with /A
— The facility or dwelling was Inspected for signs of sewage backup.
The system does not receive non•sarJtary or Industrial waste flow.
— The ske was Inspected for signs of breakout.
All system components,.�i"uding the Soil Absorption System, have been located on the site.
—ti fe)e The septic tank manholes were uncovered, opened, and the Interior of the septic tank was Inspected for condition of bar
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System orr the site has bean determined based on:
J1Existing Information. For example, Plan at B.O.H.
— Determined In the field(If any of the failure criteria related to Part C is at Issue,approximation of distance Is unacceptab
(16.3021711b1)
The facility owau Land•ore, p•n,•,Jf dLtlaraat Croat_wKaar).wrara.p6tauldad w R„r
Lth 1ar�• ioacn r►t.p6imp ,,,., « z. _
SubSurlsce Disposal Systems,
revised 9/2/98 Psessof11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM >.
PART C
SYSTEM INFORMATION
PropwtyAddresa: 89 Spice Lane, Osterville
Ownw: Maureen Yamin
D.vs of 4s+DeCt0n: 8/2 4/0 0
FLOW CONDMONS
RESIDENTIAL:
Design flow:-aj9•p•d•roedrogM.
Number of bedrooms of n Number of bedrooms(actual):�
Total DESIGN flow J
Number of current residents:
Garbage grinder(yes or nol: �
Laundry(separate system) a or t 0 . If Yes, sepuaielrsapectlon.requlred
Laundry system Inspected ys or no)
Seasonal use (yes or no):.
Water meter readings,If awl able ((last tw.o year's usage(9pd): /
Sump Pump (Yes or no):- 2�� /f—'') >/d0�,>4f s�
Last date of occupancy: cr>Q+iyl,�rB>+ Sys y prs
CommERCtALANDUSTRIAU
Type of establishment:
Design flow: d ( Based on 16.203) '
Basis of design flow
Gress$trap present: (yes or no)
Industrial Waste Molding Tank present: (yes or no)/
Non-sanitary waste discharged to the Tide 6 system: (yes or nowe
Water meter readings, If available: ---
Last date of occupancy:_
OTHER:(Describe)
lest date of occupancy:
GENERAL INFORMATION '
PUMPING RECORDS and source of Information:
System pumped as pan of Inspection: (yes or no)
It yes, volume pumped: — _9allons
Reason for pumping: A/��
TYPE OF SYSTEM
Septic tank/distribudon box/soil absorption system
Single cesspool
_T Overflow cesspool
107 Privy
4ff7��,,. Shared system (Yes or no) (if yes, ansch previous Inspection records,If any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
— Tight Tank Copy of DEP Approval
Other
A"OX11dATE AGE of all components, date InetaYedilf known)•ond sousoe ofJwfoem+don:
Sewage odors detected when-arriving at thi site: (yes or no)-420
revised 9/2/98 Page 6of 11
iil
SUBSURFACE SEWAGE DISPOSACSYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oon'tinu d)
F,Togwiy Address: 89 Spice Lane, Osterville
Own«: Maureen Yamin
Dau of I tspection: 8/2 4/0 0
BUILDING SEWER:
(Locate on site plan)
Depth below grade:,P
Material of construction:111'st Iron . 40 PVC jl�bther(explain)
Distance homyivate water supply well or suction line
Diameter
Comments: (condition of Joints, ventin evidence of h►akage,♦ic.)
Joints appear t ' 9No evidence
is vented r
SEPTIC TANK: e
(locate on she plan)
Depth below grade A2
Material of constructJon;f/�concrete.✓metalAFlberglassiaPolyethylene4Y,i ther(explaln)
Ii tank Is fnetal, Ilst age , A Js.age.confSrmed by Certificate of Compllance (Yes/No)
Dimensions:
Sludge depth: _.
Distance hom top of sludge to bottom of outlet tee ort>afflr.��
Scum tNckness: A).4
Distance hom top of scum to top of outlet tee or baffle: )
Distance hom bottom of scum to bottom of outlet tee or baffls:—AO—
How dimensions were determined:
Comments:
(recommendation for pumpin condition of Inlet and outlet teas or•beffles, depth of Liquid lov*i In relation to outlet invert, /tructurep:ntegritY•
evidence of leakage, etc.) Ue tic tank is nat presant,
GREASE TRAP: e
(locate on site plan)
Depth below grade:-A
Material of construction>lh4concretelYImatalA�Fiberglass/11f1 PolyethyleneJV�i othar(axplain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: IPW
Distance hom bottom of scum to bottom of outlet tee or.batfle:
Date of last pumping:
Comments: e•gr0y.
(recommendation for pumping, condition of In and outlet tees or baffles, depth of liquid level In relation to outlet Invert, structural nt
evidence of leakage, etc.)
rease rag
f„
revised 9/2/98 Psae7ofII
SUBSURFACE SEWAOE D13POSAL SYSTEM W31PECTION•FOPLM
PART C
SYSTEM WFORMAT10N(corrdrxu
PropertyAddrew: 89 Spice Lane, Osterville
Owrw: Maureen Yamin
D1Oe °f lr%pocdon' 8/2 4/0 0
TIOHT OR HOLDWC TANK: (Tank must be pumped prior to, or at time of, Inspection)
11"81e on Ills plan)
Depth below grad#:,&
MolorlU of conatruction:�lf Qi eoneroto/,/�net&t<kFibergIss / PolyothylenWAothor(expl&ln)
41W
1
Dimensions.
Cspoclty: gallons
Oesign flow: gallons/day
Alarm present
Alarm level: Alarm In Working order:Yes,& Nod4i
Dote of previous pumping: .�14
Comments:
1condrdon of Inlet tee, condition of alarm and float switches, ca.)
Tightor nl rli nr-T tams- a
--.._..�—.ems
Ot.STRIBUTION SOX:AAVe
ilocste on ills plan) I
Depth of ligvld level above ovdel Invert: 11
Comments:
Inge If level and dlstrlbvUon Is equal, •vidonoe of solids carryovor, evident• of leakage Into or out of ►os, etc,) —
s ri u ion box is not p magi#)+-
PUMP C 4AIMBER:�
Ilocole on site plan)
Pumps In working order:(Yes or No! �
Alarms In working order IYes or No)
-227
Comments:
Inoto condlUon of pump chamber, condition of pumps and appunenances, etc.)
llmiD C amhPr i c QQt P 'esent
revised 9/2/98 . hilt Iof11
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECT11ON FORM
PART C
SYSTEM WFORMATION (continued)
ProponyAd&*": 89 Spice Lane, Osterville
Own..: Maureen Yamin
Data of Inspection: 8/2 4//0 00
SOIL ABSORPTION
SORON SYSTEM(SAS):,&97LI� s
Notate on site plan, If possible; excavation not requlr ed,location may be approximated by nonantrusive methods)
If not located, explain:
Type: /�
leaching pits, number:CJ
leaching chambers, number:
leeching galleries, number:L
leaching trenches,number, length:
Isaching fields, number, dlmen,lons:
overflow cesspool, number:
Alternative system:-
Name of Technology: /
Comments:
inote condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
Loamy sand
of s are drv.
a 4- So 41ne u e m e ann a -
CESSPOOLS:
llocata on She plan)
Number and configuration:
Depth-top of liquid to Inlet�Vsrt:
Depth of solids layer:
Depth of scum layer. 07,
Dimensions of cesspool:
Materials of Construction: F•
indication of groundwater:
Inflow (cesspool must be pumped as part of Inspection)
.flow cesspool was not numued -
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,condition of.vegetation, etc.)
Same as above -
PPJVY:CScLL�'�
(locsts on site plan)
Materials of construction: Dimensions:
Depth of solids:—&Z
Comments:
inota condition of loll, signs of hydraulic failure, level of ponding, condition of vegetation;etc.►
Privy is not nrpspnf -
revised 9/2/98 Page 9ofII
i
3V&3VAFACt SEWA01 DISPOSAL vygToA W pwnow KKK
rAAT C
SYSTOA WFOPJAAY1011(*On* *4 .
pyop✓tyAd& 89 Spice Lane, Osterville
O.m••: Maureen Yamin
O.0 V1 8/24/00 .
Su7CH Of SEWAGE DISPOSAL SYSTEM.
IAcJvd+ d++ to it I++41 two p+(m+nsnt reference landmuks or bsnchmorks
loc+u .rl wells wlthln 100' Ilocsts whore publlo wstsr supply comes Into house)
8q �tC..e lam, s�rvi�I�e
i
nc+toorll
revised 9/2/98
SUBSURFACE SEWAGE D13PQSAL SY3TBA INSPECTION FORM
PART C
SYiTDA pr-ORMATION (corW..d)
Property Ad&&": 89 Spice Lane, Osterville
Owner: Maureen Yamin
Dou of 8/2 4/0 0
NRCS Report name
SoU Type_
Typical depth to groundwater
uSOS Dote wobslto Ashod
Observation WoUs chocked
Groundwater depth: Shallow Moderate Doop
SITE EXAM Slope
Surface water
Check Caller
Shallow wells
Estimated Depth to Oroundwater/*�Foot
Plosso Indicate aU the methods used to dotermine High Groundwater Covatlon:
Obtained from Design Plans on record
Observed �N.m
!T.ndl7on,
servatlon hole, basomoot sump etc.)
Ootermino
Chocked with local Boord of health
_ Chocked FEMA Maps
t C_hocked pumping records
hocked local e:caystors, Installo(s
used 003 Data
Describe how you established the High Groundwater Elevation, Q!gg be Completed)
Used water contours map.
Gahrety & Miller Model {
12/16/94
<�
revised 9/2/98 P.ce)lofl)
'1'OHN OF BARNSTABLE BOARD OF HEALTH
SUIISURFACR ,9FWA(;F, D1SrV3AL ,SYSTEM INSPECTION FORM PART D •- CERTIFICATION
-TYPE OA PAINT C1.6AALY-
PROPERTY INSPECTED
STREET ADDRESS 89 Spice Lane, Osterville
ASSESSORS HAP , DLOCK AND PARCEL
OWNER' s NAME Maureen Yamin
PART D - CERVIFICATION
NAME OF INSPECTOR Joseph P . Macomber Jr,
COMPANY NAME Joseph P. Macomber &''`Son, Inc.
COMPANY ADDRESS Box 66 _ Centerville MA. 02632-0066
str•gt Tovn or C ty it�t• t P
COHPANY TELEPHONE ( 508 ) 775 3338 FAX
CER'rIfICATION STATEMENT
I certify that I have personally inspected the sewage disposti`1 system nt
this nddress and that the Information reported is true , accurate , and
omplete ns of the time of - inspection , The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance or on-
site sewage disposal systems .
Check one ; ,
System 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 environment as defined in 310 CHR 15 , 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
Lhis form .
System FAILED*
The Inspection which I have con 'acted has found that the system fails to
protect the E)tiblic health and the environment in accordance with Title
5 , 310 CHR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this Inspection form ,
Inspector Signature
' 'z Date ��`��
Dtnecopy
of this certification must be provided to the OWNER, the BUYER
uh. re applIoable ) and the I30ARD OV HEALT11,
• If 'the inspection FAILED , th'i owner or operator shall upgrado ' the system
within one year or the date of the inspection , unless allowed or required
otherwise as provided to 3.10 CHR 16 , 306 ,
partd . doc
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
IZ
WIIIlrnm F.Weld p ``f � T•rudy,,Cox:,
`��6.$:rGrolury
lvgao maul Cmlluccl Sub
' V.Garamor 0 Mvid'g. un
Commliwiawr
SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION(FORM
PART A
CERTIFICATION
Property Addresa�: U-y ��/C`• /�'N J G'(�sr v���,N. ��/�� Address of Owner.
Date of Inspection: G'j— C (If different) E�
Name of Inspector-
CompanyI�.yc /iC'!%/iii�i_ f�i
Name,Address and Telephone 1Vum�er.
/•-�5����i � -s ;�,5'S DAYCO INSPECTIONS, INC.
CERTIFICATION STATEMENT P.O. Box 255�,,,.
I certify that I have personally inspected the sewage disposal syssteemZa $Ba M as t J t e information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the,proper function and
maintenance of on-site sewage disposal systems. The system:
ZPasses N
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signatures: �i ii ��f Date:
The System Inspector shall submit a copy of this ins ion report to the A Approving Authority within thin (30)days of completing i chid
Y P� PYPP �g Y Y Ys P S
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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
r
INSPECTION SbMMARY:
Check A, B, C,or D:
A] SYSTEM PASSES:
$ _X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
II] SYSTEM CONDITIONALLY PASS ✓`���
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,poises
inspection.
Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank av approved
by the Board of Health.
One Winter Street o Boston,Massachusetts 02108 • FAX(617)556-1049 • Yolophone(617)292-5 00
�� Printed on Recycled Paper
n ..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontinued)
Property Addro&s: �/"//(/ f-5�,,O Jd y— l/fte�
Owner.
Date of Inspection: /1-
B1 SYSTEM.C(LNDITIONALLY PASSES (continued) ZaPt"
Sewage backup or breakout or high&ta level observed in the distribution box is due to broken or obstructed pipes)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(&)are replaced
obstruction is removed '
distribution box is levelled or replaced
_ The system required pumping more than four 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
Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: �S/ljfl;
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 1S NOT FUNCTIONING IN A
MANNF4 WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEAL'TII AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a-well'water analysis for ibliform bacteria and volatile"orgariic'cbnipounds indicates that'the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or le;u than 5 ppm.
3) OTHER
4.1
G
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A. ;
CERTIFICATION(continued)
Property Address:-
Owner.
Date of Inupection:
DI SYSTEM FAILS:
I have dote t the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
Backup of sewage into facility or system component due to an 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.
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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
_ Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:E/61
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant thraat LO public
health and safety and the environment because one or more of the following conditions exist:-
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone 11 of u public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment progr uu
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
t
`' ?v'aw.r::w�hR�_t.'YQi,:i:.�A..iiF+'T^.�'r1!�a:f�.T��"" yyV...��.::... .�::jr� .��w.�•n':..^T�T+^ei+w�..wv.:w... ... r. .
.«�...-(•revrsecf:.+l^t-03`r95. g _ .:.. .._._,.�.,._.;_.;. ..._.,... .......___
o
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address- j �� Owe-
Owner:
Date of Inspection
Check if the following have been done:
ping information was requested of the owner, occupant, and Board of Health.
. one of the system components.have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
/46As built plans have been obtained and examined. Note if they are not available with N/A.
G'"he facility or dwelling was inspected for signs of sewage back-up.
he system does not receive non-sanitary or industrial waste flow
VThe site was inspected for signs of breakout.
L/AIl system components, excluding the Soil Absorption System, have been located on the site.
rT_he septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum.
.Z&size and location of.the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
/facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: %91d--C f ry
Owner..
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:r s•"O ¢allons
Number of bedrooms: 2_
Number of current idents: Z
Garbage grinder�r no): _
Laundry connecy�d to systemr ao)�
Seasonal use s nor no):� `� r
Water meter a�dmgs, it'available:
Last date of occupancy:
COMMERCIAL/INDUSTRIAL-
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (_yes o n If 0
If yes,volume pumped: gallons
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)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information: iC)
Sewage odors detected when arriving at the site: (yes or� /
VO
..(revfsec"l1703%95)�:.._...,r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
f PART C
SYSTEM (INFORMATION (oontinued)
Property Address: �Li �•c•v 11,Y cceJ
Owner.
of Iaspeotion:�j:D
1- "?, 90
SEPTIC TANK_
(locate on site plan) '
Depth below grade:
Material of construction:_concrete_metal FRP—other(explain)
Dimensions:
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP—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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
...
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOMI
PART C
SYSTEM INFORMATION(continued)
Property Addreaia: G�ie le-'
Owner.
Date of Inspection:
TIGHT OR HOLDING TANK—
(locate
(locate on site plan)
Depth below grade:
Material of construction: concrete_metal_FRP other(explain)
Dimensions:
Capacity: gallons
Design flow gallons/day ,
Alarm level
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,etc.)
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
// SYSTEM INFORrMATION(continued)
Property Address:
A
we
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):4PS
(locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits, number:
leaching chambers,number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool: .
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
PRIVY: O��/
(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.)
;""frevised`l'l 03 95 ".
P
a' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ SYSTEM(INFORMATION(continued)
Property Addreer+: �f✓iC //9i�e C/ :(r<'�//��-t / dim
Owner.
Date of Inspection:
SIWWH OF SEWAGE DISPOSAL SYSTEM:
t include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100,
yo
DEPTI I TO GROUNDWATER
Depth to groundvvdter: feet
method of determination, approximatio
(revised 11/03/95)'� - _....,�..._.__ .�,. _..,.:..._. _.. 'e . - .. . ...�. ... . . ... . . _._.
TOWN OF BARNSTABLE
LOCATION F SEWAGE #
VILLAGE ASSESSOR'S MAP &LOT 'QO�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILrN: (type) o L- (size)
NO.OF BEDROOMS
BUILDER OR OWNER So
PERMITDATE: �3�u COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
p�d ;
all
�a�
TOWN OF-BARNSTABLE
LOCATION 89 Spice Lane SEWAGE #
VILLAGE Osterville ASSESSOR'S MAP & LOT
INSPECTED BY: &PHONE NO? P.Macomber & Son, Inc 775-3338
' - SEPTIC TANK CAPACITY none
��. LEACHING FACILITY: (type) 2—cesspools (size) 6X8
NO.OF BEDROOMS
BiG&OWNER Maureen Yamin
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) — Feet
Edge of Wetland and Leaching Facility(If mny wetlands exist
within 31 feet/ lei 'ng faci ' Feet .
Furnished �/!
n
\ f
SL CTION A -A
e - ...,
4 PV
NOTE. ALL PIPES ARE TO 8E 4 SCHEDULE d C. VENT PIPE O Leost'24 inches tall) Att`outtET PIPES FROM THE
14 min. from (( PROFILE VIEW �yx�x�a
�house
schedule 4d PVC w/Charcoal odor Filter PR FIL IE OF` ADDITION .TO LEACHING SYSTEM D>1511sbI1TI0M BOX SMALL BEExktkp Faundotion to septic tank
... . - SET LEVFl FOR AT LEAST FT. 12` CONCRETE COVER �z - ' ':
70P OF C[]UNDATION r ELEV. t00.a0 (Assuwed) Septic bank covers must be
°ud4✓r ''.x
arRtfin b tn. of Mtshsd grade -sr-:• > - to .x' -" � .,,,•,ICY: .
Grade over Septic Tank -9s.25 Grade over D-box- 9&00 over SAS-'9b00 3' of 1 8' - 1 2` Washed Peoston 3-b OUTLET .-,'r . .. .s 2 tS
/ w_/ - 'KNOf`1cOUTS f,u ..
Y
3/4 to 1 1/2 Washed Crushed Stone v
0.02 'e PVC(CAPPED)INSPEC110N PORT TO bE y HXT
OUTLET i 4 Ln a 4
3 HOLE H-10 lap Load - Elev. -95.25 T 8 a
{LIST.BOX 3' Maidmum Cover INSTALLED AND TO K VATMN r OF GRADE _ �` ! W
` 10' NtIN S=0.01 or Greater TcP or SAS - E1w. +94 75 -a` liaise 1 w =f. 4
EXIST, FOUN to V) 1,500 GAL. . • a( am 7 Ytain�;,Fk
1 s
S+'0.01` foot or 4 - SCH, 40 Tee/
FROM EXIST. FOUNDATIt11 w 55N�� SEPTIC TANK ` Cl! SO' D� 9�t� • 0"Effective Depth
15.5'
4i ai d
l Nyou e.ttrw o PLAN SECTION 'CROSS-SECT10N t} ,
CONCRETE FTAi FOUNLM 'o ; o, 0.83` (10 inches) 7 Units 2.6.25' # ♦r4.00'a) 4
01 A o= n 3
SYSTEM PROFILE b 1n.of 3/4-1 1/2' l M 4, 3 HOLE H-10 DISTRIBUTION SOX off°
Not to State c car, 'stone c � o o 0' NOT TO SCALE
4, 4' 9 Effective length 111104�,1WiYa� !v0MW4
2.5 SOIL ABSORPTION SYSTEM -(SAS)
6 in.of 3/4•-1 1/2' m GENERAL
i
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 5" BELOW GRADE compacted stone Effective Width o INFILTATROR;HIGH CAPACITY (H-"20 LOADING)/ GEORGE ❑'BRIEN 1. ContractorEFN F Rsibllt3 for
is g noti fication
Bottom of Test Hale I 19ev.+87.00 m (OR EQUIVALENT) Not to Scale and protection of all underground utilities` and pipes.
v Obs. Groundwater - Test Hole 1 Elev.= NONE OBSERVED NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18' EFFECTIVE HEIGHT IS 10' 2. The septic tank an "distri ution 'box shall be set
/ level on 6*, of 3/4'-1 1/2" stone.
3. Backfilt should be clean sand or gravel with no
stones over 3" in size,
4. This system is subject to inspection during installation
by Carmen E. Shay Environmental Services, Inc.
P E R C 0 LAT I 0 N TEST ,SPICE LA .N�' 5. The contractor shall install this system in accordance
with Title V of the Massachusetts state code, the approved plan
and Local Regulations.
Dote Percolation Test: JULY 13, 2004 40 FOOT RIGHT OF WAY 6. If, during installation the contractor encounters any
Test Pea rformed Hy. CARMEN E. SHAY, R.S., C.S.E. soil conditions or site conditions that are different
Results Witnessed By: WAIVER (per BARNSTABLE B.O.H.) from those shown on the soil log or in our design
Excavated By. SHAY ENVIRONMENTAL SERVICES. INC. I Percolation Rate: Less Than G2 MPI installation must halt '& immediate notification be
^��- made to Carmen E. Shay - Environmental Services, Inc.
72.65' = 7. No vehicle or heavy machinery shall drive over the
�0 I septic system unless noted as H-20 septic components.
Test Hole Gj � 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends.
No. 1 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
DEPTHi SOILS ELEV. �a� i i 10. All solid piping, tees & fittings shall be 4" diameter
0 98.00 i Schedule 40 NSF PVC pipes with water tight joints.
11. Municipal Water is Connected to ALL OF The Residence and Abutting
Sandy
y LOT #10 � Properties Within 150 Feet.
I o"-8" 10 R /2 s7.25 14,250 Square Feet
lAom I THE PROPERTY LINES ARE APPROXIMATE AND
Sandy
COMPILED FROM THE SURVEY PLAN
10 YR 5/5 i i ENTITLED - "SUBDIVISION PLAN OF LAND IN BARNSTABLE, MA
DATED APRIL 10, 1952, PLAN # 30384-B SHEET2
? I I AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
AND `t I : LOT # 9 IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
25 Y I/4 I THE SEPTIC SYSTEM INSTALLATION.
ao"- 132 00 o EXISTING ;
3 BEDROOM EXISTING LEACH PIT/CESSPOOLS TO BE PUMPED OUT AND
EXISTING HOUSE ) FILLED IN PLACE OR REMOVED TO FACILITATE INSTALLATION OF NEW SAS.
_ASPHALT _ (FULL FOUNDATION) NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
GARAGE
o DRIVEWAY #89 - FROM THE EXISTING LEACHPI' CESSPOOLS TO�BETxDISPOSED
--------------- (SLAB FO NDATION) OF AS PER BOARD OF HEALTH SPECIFICATIONS.
L` '----- _ NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY
PROJECT BENCH MARK ASSESSORS MAP 165, PARCEL 005
Perc #1 l --la 7' - 2 ' TOP OF FOUNDATION LEGEND
Depth to Perc: 40" to 58" i Failed ELEV. - 100.00 (Assumed,
Perc Rate= Less Than 2 MPI r j cesspool
(Assumed)
0 NEW 1500 gal.
Observed ESHWTO - NONE OBS.- 132" Assumed !J I �'•,X =3 ,rr,�,:.; s�, - j,��4 .• _ Septic Tank DENOTES PROPOSED
ADJUSTED H2O Elev. = NONE OBS. - 132" Assumed i �; / ..eaa }` e • 1 i I``-�'-_-� 104X1 SPOT GRADE
' .tea' ,•i •�4•?i!.,.�'.. -"_ e`t. •t jY;i�`Y3='� 0
failed �� DENOTES EXISTING
4" PVC DD- (Cesspool �� X 104.46
� vent Pipe � SPOT GRADE
125.00'
��------------- PL PROPERTY LINE
cb' TEST HOLE #1
�Dl PROPOSED CONTOUR
- - - - - -97 EXISTING CONTOUR
Cb
DEEP TEST HOLE &
PERCOLATION TEST LOCATION
3-24' DIAM. ACCESS MANHOLES
• 6 FOOT STOCKADE FENCE
P LOT P LAN
f= THE ACCESS COVERS FOR THE SEPTIC TANK, 0 F PROPOSED SEPTIC SYSTEM UPGRADE
T��-;�^��:-�,t.���•__-�:�:. DISTRIBUTION BOX AND LEACHING COMPONENT �:
` SHALL BE RAISED TO WITHIN 6" of PREPARED FOR
STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE,
PLAN VIEW INSTALL TUF-TITS GAS BAFFLES OR EQUALS
ON ALL OUTLET TEE ENDS F R E D R I C K M A N S O U R
3-24'REMOVABLE COVERS
� AT
4- - #89 SPICE LANE -
• 3•mlll•Ok1RQ100•, ••'-
INLET B' m� 2' min. Inwt to outlet s. f'}--wtET
-, - O""" -11tLJ11'- OSTERVILLE, MA
N .. 10'w� tr
5' -r 5'-r Design Calculations
E E v 4'-0'min. .
b o..... Liquid e.pth Number of Bedrooms: 3 Equivalent to 330 Gal./Day PREPARED BY:
Garbage Grinder. No o MASS CAR l.�N E. ,SHA Y
� •� � tx� leaching Capacity Proposed: 440 Gal./Day Minimum 2
Septic Tank - 2 x 440 Gat./Day = 880 USE NEW 1,500 GAL. Septic Tank.
10'-0' S -a• • 501E ABSORPTION AREA: Usin 0 20 40 50
g percolation rate of C1 min./inch
-+ ENVIRONMENTAL SERVICES, INC.
Bottom Area: 0.74 gal/sq. ft. x 500 sq. ft. - 370 gallons
CROSS SECTION END-SECTIONS N P.O. BOX 627
;e.i�
Sidewall Area: 0.74 gal./sq. ft. x 99.6 sq. ft. = 73.7 gallons EAST FALMOUTH MA 02536
Providing: = 443.70 gallons G`S
TYPICAL 1500 GALLON SEPTIC TANK - T`E�� TEE/FAX : "508-539-7966
Use: (7) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, SCALE: 1 =20
NOT TO SCALE TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3' OF WASKI) STONE _=20' DRAWN BY:-_CES DATE: AUGUST 2, 2004
(H-10 LOADING) ON THE ENDS. NO STONE UNDER. PROJECT#SD609 FILENAME: SD609PP.OWG SHEET 1 OF 1