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HomeMy WebLinkAbout0112 STURBRIDGE DRIVE - Health 1 L 2 STURBRIDG D STERVILLE lLw I o � Ii 1 i f I � k Commonwealth of Massachusetts IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 112 Sturbridge Dr. Property Address Bedenkop Owner information is Owner's Name required for every Osterville MA 02655 11/30/20 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails �;/A_ 11/30/20 Inspect s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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 - Ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �o u 112 Sturbridge Dr. Property Address Bedenkop Owner information is Owner's Name required for every Osterville MA 02655 11/30/20 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: I 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 ,r ,P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 112 Sturbridge Dr. Property Address Bedenkop Owner information is Owner's Name required for every Osterville MA 02655 11/30/20 page. Citylrown 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 f Commonwealth of Massachusetts �o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t; 112 Sturbridge Dr. Property Address Bedenkop Owner information is Owner's Name required for every Osterville MA 02655 11/30/20 page. Cityrrown 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 i? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �o 112 Sturbridge Dr. Property Address Bedenkop Owner information is Owner's Name required for every Osterville MA 02655 11/30/20 page. Cityrrown 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 Y2 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.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 112 Sturbridge Dr. Property Address Bedenkop Owner information is Owner's Name required for every Osterville MA 02655 11/30/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and'location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 112 Sturbridge Dr. Property Address Bedenkop Owner information is Owner's Name required for every Osterville MA 02655 11/30/20 page. CityrFown 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: 4 bedroom permit and engineered plan on file at BOH Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No p 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate 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 112 Sturbridge Dr. Property Address Bedenkop Owner information is Owner's Name required for every Osterville MA 02655 11/30/20 page. Cityrrown 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 i Other(describe below): 3. Pumping Records: Source of information: Pumped 2018 per owner 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 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 112 Sturbridge Dr. Property Address Bedenkop Owner information is Owner's Name required for every Osterville MA 02655 11/30/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Existing septic tank, new d-box and leach chambers 2013 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 24"feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 i Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 112 Sturbridge Dr. Property Address Bedenkop Owner information is Owner's Name required for every Ostervilile MA 02655 11/30/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 18"feet Material of construction: ® concrete - ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound, inlet cover raised to 6" of grade, outlet cover is under patio pavers, scum and sludge measurements taken at inlet cover If tank is metal, list age:g years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No I, Dimensions: 1500g Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle >12" Scum thickness trace-1/4" Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �o 112 Sturbridge Dr. Property Address Bedenkop Owner information is owner's Name required for every Osterville MA 02655 11/30/20 page. City town 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): I Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle j Distance from bottom of scum to bottom of outlet tee or baffle 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 ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �o 112 Sturbridge Dr. 'u 9 Property Address Bedenkop Owner information is Owner's Name required for every Osterville MA 02655 11/30/20 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 011 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.): H-20 D-box is 3' below grade, cover to 12" of grade, no adverse conditions observed t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts i? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 112 Sturbridge Dr. Property Address Bedenkop Owner information is Owners Name required for every Osterville MA 02655 11/30/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ 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 Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 112 Sturbridge Dr. Property Address Bedenkop Owner information is Owner's Name required for every Osterville MA 02655 11/30/20 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.): Chambers are in the paved driveway, they are of H-20 construction per BOH record, steel cover to grade, chambers are damp at this time, no indication of past hydraulic failure, bottom of chambers is 5'6" below grade 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert I 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.): �J 1 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e 112 Sturbridge Dr. Property Address Bedenko Owner information is Owner's Name required for every Osterville MA 02655 11/30/20 page. CityrFown 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.): I I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 f — Commonwealth of Massachusetts Title 5 Official Inspection Form ~ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a u 112 Sturbridge Dr. Property Address Bedenkop Owner information is Owner's Name required for every Osterville MA 02655 11/30/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately II t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 1WO20 Assessing As-Built Cards TOWN OF BARNSTABLE LOCATION ILA- t SEWAGE# ,-)0i 3—L VILLAGE ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. ZML~a-4':ri I CW ; -x?I SEPTIC TANK CAPACITY 15:k 1 144 1<Z-0 :19%/LC LEACHING FACILITY: (size) 3,3.! X 0--!W t4� NO.OF BEDROOMS OWNER Et: lGc�� PERMIT DATE: -!6 13 COMPLIANCE DATE: Separation Distance Between the: Maximum Ad#usted 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) ' W Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 fed of leaching facility) Feet FURNISHED BY e ♦ f Z-3 3+0 7--j • 5 fl3�1•J . P a6* 5 ( OD 4 ✓Fin i https://www.townofbarnstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?mappar-165048&seq=2 1/2 .5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v 112 Sturbridge Dr. Property Address Bedenkop Owner information is Owner's Name required for every Osterville MA 02655 11/30/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >120" 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: 2013 NGW 120" i Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4' seperation per 2013 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the site at 50'msl and nearby surface water at 6'msl You must describe how you established the high ground water elevation: See above t Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form j- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 112 Sturbridge Dr. Property Address Bedenkop Owner information is Owner's Name required for every Osterville MA 02655 11/30/20 page. City(rown 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 I 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 4 - Town of Barnstable P# do Department of Regulatory Services A 3 IARNSTABLE, Public Health Division Date 9 MASS $ .. 039. 200 Main Street,Hyannis MA 02601 ��f0 MA't a Date Scheduled 0_3 Time Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: Witnessed By: hOi k IDi�T" ENEgtAI;I v OlFel�ia i 101+I Wit. Location Address 'f S-1wY rI ( 9 �U r. Owner's Name a e4,<. �(Q- Address Assessor's Map/Parcel: 16 S141_ Engineer's Name I W h C_ y e_ NEW CONSTRUCTION REPAIR Telephone# , 0(f 3&& 4tis 7l Land Use L o,w Slopes(%) 19 - Surface Stones No h e Distances from: Open Water Body > f o o ft Possible Wet Area >00 ft Drinking Water Well >OC/ ft Drainage Way > f GV ft, Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) N I� �0, I ;V - o S-E�tl' br;d5e V� Parent material(geologic)G(a6.'CAI G,j u,C,Sh Depth to Bedrock UG _Depth to Groundwater: Standing_Water in Hgo�le, N/A-- �W_ eeping from Pit-Face_ --&/ Estimated Seasonal High Groundwater /Y IA-" DETERMINATION FOR SEASONALTHIGH WATER TABLE 4. Method Used: 'VG'ti Depth Observed standing in obs.hole: in. Depth to'soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index We1l# Reading Date: - Index Well level Adj.factor Adj.Groundwater Level PERCOLATION,TEST' ..t. nate3/!� yTi me Observation u - Hole# Time at 9" Depth of Pere 5_0 Time at 6 Start Pre-soak Time @ �� Time(9"-6") End Pre-soak IU, IS Rate Mm./Inch L Z i Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Al, Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP OBSERVATION.HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) O-�z SL IoYA 1/� )z-zO B L ZU-I zO c M ,'DEEP OBSERVATION HOLE LOG Hole# 2 Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) L s 10m /C DEEP OBSERVATION HOLE LOG Hole.#, Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) -- — -- _.._........_..._.....— DEEP OBSERVATION HOLE LOG ,r Hole#r Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) Flood Insurance Rate Man: Above 500 year flood boundary No Yes V Within 500 year boundary No Yes Within 100 year flood boundary No Yes Death of Naturally Occurrinz Pervious Material Does at least four feet of naturally occurring pervious.material exist in all areas observed throughout the area proposed for the soil absorption system? > If not,what is the depth of naturally occurring pervious material? r Certification I certify that on S�l Z (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required ytr�ain,,iin'g,expertise and experience described in 310 CMR 15.017. r Signature )b '"} '"�'��`w� Date Q:\SEPTIC\PERCFORM.DOC t TOWN OF BARNSTABLE LOCATION p1 e 2.i I SEWAGE# VIL's AGE ASSESSOR'S MAP&PARCEL 14,65--*Y INSTALLER'S NAME&PHONE NO. LT SEPTIC TANK CAPACITY 11�i s 1 Vt6 1 AGO Z LEACHING FACILITY:(type)—i. (size) J�Pam• e -� NO.OF BEDROOMS OWNER Bt�b LW l PERMIT DATE: —IE, 03 COMPLIANCE DATE: 51 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility !!�bFeet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) ,'41 ✓, Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) —•Feet FURNISHED BY rS ®D 0 p ✓Fir No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppfication for Vona *Pstem Construction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. f +u r b r; e'Dr, Owner's Narnti,Address,qnd Tel.No. 50"8'-41/8 d S 54S,9 � leQfAssessor's Map/Parcel 6 $ S Installer's Name Address,an Tel.No. 506- 77 �43 e,f9 Designer's Name, and Tel.No. &/4. ° s ate,V151 AAA oa&-)s' Type of Building: Dwelling No.of Bedrooms Lot Size ,�a $�� sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Vq U gpd Design flow provided Ste^ gpd Plan Date &" Is) 'a ol'3 Number of sheets ' Revision Date Title 1 e i�Pja_,- 4 j IA S6 ct . ll ,'`e- Size of Septic Tank Q V_'AJS Aqn Type of S.A.S. &9j -5Cx3q j�- Description of Soil C. I_. a3 A 331 ii Nature of Repairs or Alterations(Answer when applicable)Ya" W 3 Pln-x _ - j E S=q drroas1� ,cam.43pi,D1 r &_ t Z%-:?, �,. X 3-3-S'l Lam}, ,D� 51� c A3�Lz, Wiz_ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental a and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si ed Date 6eA 3 Application Approved by Date e,3 Application Disapproved b Date for the following reasons Permit No.2-0 Date Issued (102,013 Na: 26(3 - ( z 1 ci,. !"T: S � i � o Fee /Cc I� Cc r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. \ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 11 \� 0(pplicatlon for �MIsposal 6pstem Construction PPrmit Application for a Permit to Construct( ) Repair(kf Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1 VT U(6 r J Dr, Owner's Name,Address,4nd Tel.No. - b 2f 6 S%8-3 9 �h�er Assessor's Map/Parcel 1(o,j 8 2.rVi b1L. // � r r Dr. &St• Ut Ig C7_.4s — Installer's Name Address,and Tel.No. SvS- ��� %35'q Designer's Name,Address,and Tel.No. /3arkA/// Cv.�sf �• ,v�c�C��e �,:�e,,r�,r•� s�,.�4�:�sf. s Ali Its 0>4S/s, MA OX& 5` Type of Building: / Dwelling No.of Bedrooms Lot Size w) 50 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( Other Fixtures i�' / Design Flow(min.required) '!U gpd Design flow provided ly 5.5� gpd `mot Plan Date q(ck 15l a.01�j 'Number of sheets Revision Date Title 7 41,-, -;S i'1-e_ 1 cur, c .]L 11I C)t of h riCP l X/r}t' full I `e 1 ��^ Size of Septic Tank�JZ e_X)S4 1C%!1 Type of S.A.S. 1-i� 4 3-`5C o14 c,� f� .�1� M1t(1@l1 Description of Soil `1 Nature of Repairs or Alterations(Answer when applicable) YkA4 r I{ aU t_i t?0,( 3 3- l( �ca sc 4 CY ma's�- 0_�yi m&4 d n cl. I �k .?53, _k 0 X 3,S 'L S/--e_Le elm, (l luc Ne` ,) tics �NJ is A U t Oer Date last inspected: Agreement: . The undersigned agrees to ensure the construction and maintenance of the afore described on site sewage disposal_system in accordance with the provisions of Title 5 of the Environmental C de and not to place h system in operation until a Certificate of 1-1 Compliance has been issued by this Board of Health. Si d --' Date 1191, y., Application Approved by �,�s'j s Date [ (6 20 r 3 Application Disapproved b V Date for the following reasons Permit No.2Zo (2-1 Date Issued �1 46 Z013 ti -------------------------------------------------------------------------------------------------------- ---------- - TH E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired� Upgraded( ) Abandoned( )by 8qq r�,164; Cnstn. 10" .l n C at 1 k�S\-oOn(Ar,9 a eJr. - C5{-c-.ry i 1 Ie has been constructed in accordance with the provisions ,oJ/f Titlee�5 and/the for Disposal System Construction Permit Noo..70i3- (Z`l dated q 1 /L©t 3 Installert�,�('-t/lUPtSt`i't1c or ; 1--,,c. Designer DOWn 151¢ t`n� n��r�M T,-r— ' #bedrooms Approved design flow S S and The issuance of this permit sh/al n be construed as a guarantee that the system iv�functionf as Date / � Inspector �t/��lir &/ 1 ks v V -------------------------------------- ----------------------------------- ---------------- ----------------- --- ----- -- No f Z 1 Fee. 'o THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS i Misposai *pstem Construction Permit Permission'is hereby granted to Construct( )/ Repair( Upgrade( ) 1 Abandon( ) System located at- �/ )4 U f rlOfoe �� tug and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:C nnstru tion must be completed within three years of the date of this permit. Date G� / I Approved by NRY-15-2013 09:43 From:BORTOLOTTI CONST 5084269399 To:15087906304 P.1/1 FRDM :down cape engineering tnc FAr'i NO. :15O8362geGO Maad. 15 2013 09:52AM P1 -r,o rn of S � .o 3'haiL]lw 9. 4sr+'l��lr;,A&,�Ut aetnr 'P oIjIfe TTeri lth Division '���;�pM1er�:h. �'�ua7u.s�t♦Ie'�4'����u, ltpie'F�ttaltr 200 MRim! i�asef, FDg��riroik,i4�f.�.02601 51t8-igo 690 ,ueirt��.: s �ri�ifia:�adi�an d�'t�a gaate. r �� �-� swage permit* ���� ~ �'�/ Aboese eq IVlfmg�wareci /+�� ��"' ID�s�;na>r: d+.J.�..� Q_ h 7m�tilc:n•: Ar" 7z1Z �-►� a �vj Ir- 4 Oil was issind A pen„i t to insdall a nfiEitivi)' o afi � rl Ve h ,,tt OLL a,d�ei a CIrr�w.O 1,aeNU.".6r.3C Y / /" (t�tlC1lliBl�� l cerli fy tWt TJ P: sepila !,q Aem rermnued asbuvu wus iulsWlyd auh=itiaI)y auuoyJi the. ri�.si,�, 'whit is tutiy i,mi de ln.innr qi roved uhwage6 sonh aa3 lateril relr>cation. ul ILLt di.4tribt'ita a lox andlur soplin t�rlis. I ,,e-r6{y t:baL thr. saptc r,-Intert reftq•I:noed rabtw; wt w in9tn•Ued with rjor changes (1.e. &rnj9tr;r them 101 1Ptr,-j J.reJncatirn1,,of the SAS oT aT,y vtsxlir, l.caloeoti,n,�,.of any carryyjun- t of the s-c-ptir uystarn)b al ai acaordaa�*.r.with Stwo& 1.0cul R'bp"WabouR. Plan,ttrv=ion[n rd FLg- y dpsi(',ex tip fq lrYv�r. ' DAN II9L A, On!,,Ul1 r' OJAI C S 4 �„'ulfa�re) ' f„iVlL ' No 405 � ONA I (U ai;ai;;��.c,'� igr►iiii�tc. ,�?c:Nlin'�c�r'a �Cw,i� l,rue�) i;ER` WAIL, —(11F d�[911 ;a�(:id "v�", .l:, hTi)�'•:13� �5'L'lT.}'>s T7.1�1'�'J3. A[}'I:H Trim A�).�1� �lYla A�TitJiTlT t...ARi� ,p, n�ar,b;,• r, gait�ri ;a��,�t�r�rnnL��� y�r �� ;�',t,.��nr,vT,�l�r�, � ,...r��•rr, MAY-15-2013 09:45 From:BORTOLOTTI CONST 5084289399 To:15087906304 P.1/1 FROM :down cape engineering Inc FAX N0. :iSM3629WO May. 0 2013 09:52AM P1 nrtR �e% .3J'n�C:li9rC ���xi�'C:1fE �iVn61d31� 200 MAttltS1rewer,Hyannim, 'WA 02601 U;t��s; 56R flfi2-�t6�!�I pm: S08-'!9D 6104 Ziuna�Ul�. tA� er Cer6fie floor Fout Date:' J-3 Swv mlr 1Nav�!mifl;� ��/3 � 12. Mseaa '� I�fia'a,•cc, elegy lief®��dr: ��.10,.J�..��.. �.... .. � �n Y�ro� l�:n: �Or�� c�l�-►� Addreas- Y Addrcms: 17 Oil ���G /3 8jaP4 J t�.�S14X-efts isslarj A pennit to in-atsLll ti. n;��ull�r� r� p . iu s stc. at.. � rJ VJ1�✓� hasull uu A.11mi g.clrr�a Icy s Y ..�. .' .1 1�►' C (Lich+tree) i re ry,tat thf' T-Ptir, Tefc,-entwd above wuC iu8tga&d qubstantially L'Lt;uwding t.r► ILL. dr5j,np,whW11 L Ay J,tll:ll7de LCi.iloT aprWaVed UhilllgW Or.11 an I'Veral, ralnc 8011.01 the di:tralutiorl,bnx aad/ur siV. IiC.MiuC, I (v,r dy t'ha t t�, sgfic !.,item referenced illiove, wtu+ jy,Os :Ued with major Cl ungc* (i.e. ^' j ieAft'l•thall 1 C' ]8tfrt9,1 rclrcntinn.of the SAS t)r ury vertusal.ic:lMcatrrin of any C;ATl'1POM TC R[die:sCNtir: sys'r m) bLI'1 m wxordawn witil ai'Ato R,e;kI irlow. Plau It-orlon 01 ncsti u'cl U- y 61mipt x to founw- 1'A�JFAtA , 00 ---- NUS A, OJAIA (ii ZEliri•'s �ipafiar,,j_ civil, No 40 WAT g,,A6U_.1+ ;7.T x 1 i ,f.&f'T�BLE PUBLIC )iUj j t R �9 i(:lt !a'taT 13J>< 'ilT!;X� TA�1'i[7J, AnTA THIS ro.R&A& ..��T3rIRN CAR11..AL4 COMMONWEALTH OF MASSACHUSETTS x EXECUTIVE.OFFICE OF ENVIRONMENTAL AFFAIRS . v DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A . CERTIFICATION Property Address:. n^ _ �� � MA Owner's Name:��nx' • of Owner's Address: ' ,V Date of Inspection: Name of Inspector pleaseprint) ` Company Name: i Mailing Address:�.ow�Pir: Telephone Number:. 7�� • 5�99 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,.accurate and complete as of the time of the inspection:The inspection.was.performed based on my training and experience in the proper function and maintenance of on site.sewage disposal.systems. I am a DEP approved system inspector pursuant t Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes eeds urther Evaluation by the Local Approving Authority. ails Inspecto.r's Signature: Y Date: l�d) The system inspector shall submit a copy of this inspection report to the.Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer; if applicable,and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I Page 2`of 1 l OFFICIAL INSPECTION FORM'-iNOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART T A CERTIFICATION(continued) Property Address: _qg d&b_/_0j Owner: Date of Inspection: Inspection Summary: Check A,B,C,D or:E I ALW A17V S complete,all of Section D A.., stem Passes: Lhave not found an information which indicates hat an o e> ail r y y f th f u e criteria described-in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria n Ievaluated are indicated below, Comments: B. System Conditionally Passes: One or more system components as described in tt e"Conditional Pass"section need to be replaced,or repaired. The system,upon completion of the replaceme.n or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the lor the following.statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or. he septic tank(whether metal or�not) is structurally unsound,•exhibits substantial_infiltration.or exfiltration or ank failure is imminent. System will`pass inspection if the existing tank is replaced with a.complying septic tank'as' pproved.by the Board,ofRealth. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or hial static water level'.in the distribution box due to broken'or obstructed..pipe(s)or due to a broken;settled or uneven dikribution box:.System willpass'inspection if(with approval of Board of Health): broken pipe(s)are re laced obstruction is reniov d distribution box is:.leveled or replaced ND explain: The system.required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board:of Health):. broken pipe(s)are rep aced obstruction is remove ND explain: i Page 3 of I'l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM.INSPECTION-FORM PART A CERTIFICATION.(continued) Property Address: Owner: o Date of Inspection:: 3�n1 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 Boarc]'of'Health determines,in accordance'witli*310`CMR 15.3.63(1)(b).that the system is not functioning in a manner which will protect public health,safety and the:environment: _ Cesspool or privy is within 50 feet,of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a.ntanner that protects the public health,safety and environment:. The system has aseptic 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.I of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of private.water supply well. _ The system.has a septic tank and.SAS and the,SAS is less than 100,feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A,copy of the analysis must be attached..to this form. 3. Other: 3 Page 4 of 11 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART A CERTIFICATION'(continued) Property Address: �4 Owner: Date of Inspection: I D. System Failure Criteria applicable to all systems: You most indicate"yes"or"no"to each of the-following for all inspections: Yes Nof Backup of sewage into.facilityor system component due to overloaded or clogged SAS or cesspool - b/ Discharge or pond.ing`of effluent to the-surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ YU 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 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface / water supply. Any portion of a:cesspool or privy is Within.a Zone 1 of a public well. 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,gre'ater than 50 feet from a private water supply well-with no acceptable water quality'analysis. [This system passes if the well water`analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates`that the well is free from pollution from that facility and the.presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria �f are triggered:A copy of the analysis must be attached to this form.] :(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large'system,the system must-serve a facility with a-design flow of 10,000 gpd 045,000 gPd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large.system's in addition to the criteria above) yes no _ the system i.s 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 lI of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system-in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 I Page 5 of 1.1 , OFFICIAL INSPECTION CTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'F.ORM PART B CHECKLIST Property Address: � - 'y Owner: � '4. •. Date of Inspection: 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 ow_rer;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? w Have large.volumes.of water been introduced to the system recently or as part of thi,s.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 t� 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 o(scum? Was.the facility owner(and occupants,if different from,owner),provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System(SAS)on the site.has been determined.based on: Yes no Existing.information. For example,a plan.at the Board of Health. - _ Determined in the field(if any of the a failure criteria related to Part C is at issue.approximation_of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 1 I OFFICIAL INSPIECTIUN rORM—..NOT FOR VOLUNTARY ASSESSMICINTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPI';CTION.FORM PART C SYSTEM INFORMATION Property Address: dd/y% Owner: Date-of Inspection: gzzszo FLOW CONDITIONS RESIDIENTIAL Number of bedrooms(design): ` Number of.bedrooms(actual):• . DESIGN flow based on 310 C' P5.203 (for example: 11:0 gpd x#of bedrooms): Number of current residents: Does residence'have a garbage grinder(yes�or,no)�'{ Is laundry on a separate sewage system (yes or n .o)jk if yes separate inspection required] Laundry system inspected es or no Seasonal use: (yes orno) }� Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no : I — qq Last date of occupancy:. COMMERCIAL/INDUSTRIAk/X1Q— Type of establishment:. Design flow.(based on-310 CMR.15.203);, gpd Basis of design.flow(§eats/person"s/sgft,ete:): Grease trap present(yes or no):— Industrial waste holding.tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):'_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as4tpof the inspection(yes or no If yes,volume pumped: ga. 11ons How was quantitypumped determined? Reason•for.pumping: . • OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _:Privy _Shared system.(yes or no)(if yes,attach previous inspection records, if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy'of the DER approval —Other-(describe): AP roximate age of all components,date installed(if known)and source of information.- AA- Were.-sewage odors•detected when arriving at the site(yes or no) 6 I Page 7 of 11 OFFICIAL INSPECTION FORM=,NOT FORYOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 941t ;(�n�i��D Date of Inspection: BUILDING SEWER(locate on site plan) � . Depth below grade: , Materials of construction:_cast iron 40 PVC other(explain): Distance from private water supply well or suction line: 4 Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: (locate on site plan) Depth below grade: 001 Material of construction: concrete_metal_fiberglass polyethylene _other(explain) ' If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a.copy of certificate) Dimensions: )0,,q'N La# ` . Sludge depth: 3r !/ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 0 Distance from top of scum to top of outlet tee-or baffle: y �/ Distance from bottom of scum to bottom of outlet tee or baffle: _ How were dimensions determined: Comments(on pumping recommendations, i let and outlet tee or baffle condition,structural integrity,-I levels as related to outlet invert,evi ence of leakage,etc.): ,van GREASE TRAPAOocate on.site plan) Depth below grade: Material of construction:_concrete_metal fiberglass_polyethylene_other., (explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet.tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage;etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARVASSESSMENTS SUBSURFACE SEWAGE DISPOSAL"SYSTEM INSPECTION FORM PART C :SYSTEM INFORMATION(continued) Property Address: Owner: 49,e. Date of Inspection: ,� I 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: (/(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 akage into or out-of box, etc.): PUMP'CHAMB!� (locate on site plan) Pumps in working order(yes or no): . Alarms in working order(yes or no):. Comments(note.condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION(continued) Property Address: , ) he�� Owner: !�aA ®� � Date of Inspection: 91� Jo/ SOIL ABSORPTION SYSTEM (SAS):._(locate on site plan,excavation not required) If SAS not located explain why: TYPe leaching.pits,number:, leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields,number,dimensions: overflow cesspool;'number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil; condition of vegetation, etc): io j Z IV le" Az ALO CESSPOOLS:�L_(cesspool must be pumped as part of inspection)(locate on site plan) t Number and configuration:` Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIY�Cate 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:): , , 9 i Page 10 of l l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION S ECTION FORM P LR�T� C SYSTEM INFO1tMATION(continued) Property Address:. �o� � �-GC ��� ✓� Owner: c Date of Inspection: . 9113101 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system includir g ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A i i Y" ---- .7 O 0 i 10 i Page 11.of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 3 Date of Inspection: SITE EXAM Slope , Surface water Check cellar. Shallow wells Estimated depth to ground water l!. feet' Please,indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed, Observed site(abutting property/observation-hole within 150 feet of SAS) Checked-With local Board of Health-explain: hecked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: ��e 11 r G � _ Permit Number: Date: Completed by: e eg HIGH GROUND-WATER LEVEL COMPUTATION " ;>> . Z �� Jir Lot No. Site Location: Owner: /UG j� Address: !`Z /'' A Contractor: ®�t�G� -�� , �r Address: � va y tom'. Notes: x ; STEP 1 Measure depth to water table l l to.nearest 1/10 ft. Date G/�Ga month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well....................................... ` OB Water-level range zone ...................... STEP 3 Using monthly report"Current Water Resources Conditions" determine current depth to qc/61 water level for index well ........................... month/year STEP , 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) determine water-level adjustment ° STEP 5 Estimate depth to high water by subtracting the water- 3` level adjustment (STEP 4) from measured depth to water ���) level at site (STEP 1) ................................... Figure 11"Reproducible.computation form.' 15 .r ®n �✓� /�d,�lyre " I Pot 46 j . I oo.oo i ,Pot 4 7 i 0.24 Flc, .('o-t 48 ti `3'. #112 i ( 40 � wide ti I I I Shaded area a 13 2.-0 -cl `` p�xpoied Vie. £nr�toachmen t on a t tze-t sine as ahown. ij 3' r a o' . G•Z I ' iSlhe dwet,l ins al own on -this. pin -i i ..coed on the g wwld as -dlwwn heaeon, and met t/z gowns atb.e aa te�e en t i when built. I I'J'uc,LdLu done r\ C dz 6acki 30 a t. I I0 t dide 0 4e" St tz 1 tan of . and in. Ld.teh..tJitte, ti9 �?o t Cap lton l~;:i tcAd-t �')cp 16S par,. �8 6 einf a tot- 47 as a/wwn on ZC.73/373 13 ,A.2 3/ ate 8-16-q5 Scate I"-30 ) qtt Cape Zncrinzea inc Uq /datbot Pd. kyan.-,�, !''19 02601 OF o tLNE v .32490 i dJ�o FGISTEa�s�P��, i N 1 . i � 1 open 5..� AA cN ;O �IISTlV6 r'�A►+a1Ly12bvw1 � ! � I . .LX/ SnIj G, tLook pt✓�N C, rN lrc,yrz 4 i Z ��i j � P 5 4F a i S. j L I ! I I I ! ! j , I . i iZX/0, je1t76C . 1 I j !! -I ! 2X$. Je.4F1"MS I 31,f. . , I ,Tow► Ycil • I j i I : I I s 4 Lf i i i t 1 : i i ! lJ'1vN. 1 I { i f 12Xy :STun�s I ! ; ' ; i .! ► I. i j j. I I .1 i t .1 /uSVLA TIOVTML ! ! %PcYWDov i � ! i : I I i I I ! I alih Division isi�n i I. I. I c r i c ciA s�I Barnstable o i I PO Box 534 ' Hyannis,Massachusetts 0260:1 — — - - ti Fax(508)775-3344 { f"'� Phone(508)'7 6 I j+ .�� I : i 1 I c• F N�E'AM�&I �a £bVL '70 : • { { I : : L ! 1 : ; +- 30: (�0 i N v TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE �'���—� ASSESSOR'S MAP LOT,/ �''y� INSTALLER'S NAME PHONE NO. Q oVt-4-*4v f9 : C-6AJ S i SEPTIC TANK CAPACITY LEACHING FACILITY:(type) size) NO. OF BEDROOMS_ PRIVATE WELL OR BLI ATER BUILDER ORCOWN�E r DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: �1�� VARIANCE GRANTED: Yes No J v I :go/42 ea- r , 30' 60 47 i A J 165 7 L1,9 No.. ....j............. Ftns......... ..-__...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Di►i,pnial li arlai Cnnmitr7PanTnpdivi "uSewage Application is hereby made for a Permit to Construct ( ) or Repair � Disposal System at. kl d . ...._ �.� -._117--•ce ---------- Address r No. ............ 0 . a - .-- - ---• ---•- P-XCt��s......_ 1.1j .... 1 sr���e Inst lle� r Address Type of Building o Size Lot-_llf.C_ ....Sq. feet ..� Dwelling—No. of Bedrooms.- . _.._Expansion ttic ( ) Garbage Grinder ( ) `4 Other—T e of Building a —Type g --� St dC.GNo. pe ____. ............. Showers (�— Cafeteria ( ) dOther fixtures .---- - Q2 ••-- ------------ ---------•••-•-----•------•-•-----•-•-----••._............... W Design Flow......_....................gallons per person per day. Total daily flow....................... � t�it W Septic Tank—Liquid capacity__ __._dgallons Length--- ..r.._.... Width----4?------- Diameter................ Depth_._��........_.. x Disposal Trench--. o. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. G.X7-De th below inlet..._�Q......... Total leaching area..................s ft. � Seepage Pit No.......... ......... Diameter........ p g q. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by..........-------•---•-••••••--•-• -----•----•---••---------•---••-•-•-•• Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ Li, Test Pit No. 2................minutes per inch Depth of Test Pit--.-_-_--.____-_•- Depth to ground water........................ 0+' M�j_ -------------- j 0 Description of Soil•••--!�JEL.` Vf!�1------5..�_.. ..j-•--... ---------------------------•---- -----------------• -•--••---••----- mC�- ..........................-..........................--------------------------------------------------------- ---- -------- ------•••--- • ---...._. U Na re of Repairs or Alterations—Answer he applicable....1,�s /`.___ .... G.. � `tag ........._. �..5 _, ' .� 1,;K5---------------------------------- --------------- ------ ......................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned rt era e.. IreJy�� system in operation until a Certificate of Compliance h9oeen issu d t Signed ... . - Application Approved By .... ....... �2� �(- , .- ....... ...... .. ........- ------ . J------------ .......... ........................... Date Application Disapproved for the following ream s: r Dare Permit No. / .. .. Issued ...............`........................ ------------...---- are. .... ...... ................... Nol 01' - Fita Z2a THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH r TOWN OF BARNSTABLE _ Ap.pliration for Di►ipoiul Works Tonlitrurt-on Famit ���mj� Application is hereby made for a Permit to Constrict ( ) or l.tepair (� an(individual Sewage Disposal System at -Address. ._S � h i t i�� No. a �or - C,/ / lgaxUSA . G nst�.... I - e Address // U Type of Building —' Size Lot..�L).n f�.�....Sq. feet Dwelling—No. of Bedrooms........... ...........................Expansion Attic ( ) Garbage Grinder ( ) 0`4 Other—Type of Building __�PS(��2�1 c�No. of persons--------- ............. Showers Cafeteria ( ) Other fixtures ----- Ct t �f'c� l !5 ( �- G- -!-------------- W Design Flow............:5—� ................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/_J`___edgalIons Length...L ....... Width....------- Diameter................ Depth...11� x Disposal Trench— o. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter........ G.r17Depth below inlet..../ ......... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ................J� . --------------•-_ ------ DDescription of Soil..... - C�/(�lM_.....l__ &,�C .1�.? ........>S._�r-Mtn'................................................................................. x w ---------------------------------------------------------••-`------•---•-•......-•----......--•---------•-----...... --- .... -•-- U Nature of Repairs or Alterations—Answer hen,applicable.-_./_J S .. ...........C..._�` � .............. ---------------------...............................................................--------- ------------ ----•---•--•--•--...... , Agreement: a The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned f rt er ag, -.lace he system in operation until a Certificate of Compliance has been issued by th bAr- e J l Signed �..................... y . Application Approved By . , L!...'.�.!" ................................. . .r;....................� {p ............... .................... ................../ / � ...:`.�. ' Dare ApplicationDisapproved for the following yeaso�............................................................... ....................................................................................................................... .......................... .... . .............I....... ....................................................��14.1 Permit No. - - ---------------- Issued ------------� j�� Da,e...... Date t 7---------------------------- � -. -- — — _---....— —_---._..—.—__.— — THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH \ TOWN OF BARNSTABLE Tertifi.rate of Tontplia re T IS S TO CERTIFY, Th t the Individual Sewage Disposal Sys..ern stri c, d/( r Repaired ( �)� �✓ (( by . G .l l(J ..j.........1'.... C .UCH.7`th S--- C�1 J_�.(C c S_/ ../....... .-..........�J />..�..... at �1.a- . .) �//�--- �1.C• P....Ae U 1 s7� �9?-0..W ------------------ has been installed in accordance with the provisions of TITLEiE of The Sta e. Environmental Code as described in the application for Disposal Works Construction Permit No. . .....�-". ... _ _1. ./... dated ..... _...................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT ONSTR ERAS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ,/CS` �1 DATE......._.........................._........ ...._._.......... .. ......_.... Inspector ....._............... - ...... _..... -�......,...._:......... /// J/ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN, OF BARNSTABLE No...I...�......... FEE. ...... Rio oo�t1 xko notrur2nPrrmit, 42 Permission is hereby grante -- �! e + - - to Construct ) or �a�r n �ndtviA Sew. e -isposal/ 'tem� ) ' at No. .�_� ..-... .I- /e:�A� -z .6.1 1/....J ---- --------- �//•LPL ---------------•----------.-- � Strcct as shown on the application for Disposal Works Construction PE—rnit No.�_--- Dated_ Da-ted____01..:................ .......... G ............ ... h ? —DATE � b , Bar Flcalth T9-- 1 v v FORM 36508 HOBBS&WARREN.INC..PUBLISHERS AsBuilt Page 1 of 1 '( �-L TOWN OF BARNSTABLE LOCATION %/.2 SEWAGE VILLAGE ASSESSOR'S MAP & LOT��Oyr INSTALLER'S NAME & PHONE NO._90✓TlL0is 6,9--k57— SEPTIC TANK CAPACITY- /�Lb LEACHING FACILITY;(type) /��l� (size) G x6 /Pao(-5 NO. OF BEDROOMS PRIVATE WELL OR BLI WATER BUILDER O QI� .V�NE i 4A, DATE PERMIT ISSUED: 5//'� _ DATE COMPLIANCE ISSUED; VARIANCE GRANTED: Yes No • �Soy y� � r 1►0 O . 7r http://issgl2/intranet/Propdata/prebuilt.aspx?mappar=165048&seq=1 4/10/2013 NOTES a SYSTEM PROFILE 1. DATUM Is APPROX. NGVD ALL SYSTEM COMPONENTS SMALL BE MARKED WITH MAGNETIC TAPE OR ./• (NOT TO SCALE) COMPARABLE MEANS FOR FU1L1RE LOCATION. 2. MUNICIPAL WATER IS EXISTING (TO BE SLEEVED) ACCESS COVERS TO WITHIN 6" OF FIN. GRADE PROVIDE C.I. COVERS TO FINISH GRADE 2" PEASTONE OR GEOTEXTILE\ 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.TOP FOUND. EL. 52.85' FILTER FABRIC OVER STONE �a Locus 52.3 MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 52.2' 0 �, 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO I PRECAST H-10 WATERTEST D'BOX FOR LEVELNESS H- 2O RISERS (TYP.) 2'0 4"OSCH40 PVC MORTAR ALL qe� PIPES LEVEL 1ST 2' 4 COMPONENTS INVE�i' IN 47.9 4 5. PIPE JOINTS TO BE MADE WATERTIGHT. sou h 6 r ENos (TYP.) [-SIDES48.9' 00 JO 10" EXISTIN 14" r '�'�° ° '` o'°o°o°° 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH t. TEE SEPTIC ANK**TEE 49 5*, ' ° n ®®®® ®®®®- ®®® MASS. ENVIRONMENTAL CODE TITLE 5. 000000000000 6.. MIN. SUMP - oa°oo°o°oo ®®®®®®®®®®® ®m®®®® GAS BAFFLE.., °O°o°°o°°o�°0°,0°4 12" MIN. DIM. o°°°Oo°oo N °goo°o°° 48.17' 48.0' °°°°°°°° °o°o°a°o 45.9' 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO°°°°°°°° ° ° ° ° ,: •.:�:. �:.......: BE USED FOR LOT LINE STAKING OR ANY OTHER PURPOSE. 00000000oo0000000000000000000000o0o00ogog000; °o°,o°oo�ononono.,00°00000°00040o�°won°n00000 H-20 500 GAL. LEACHING CHAMBER$ BY ACME PRECAST OR EQUAL 3/4"-1-1/2" DOUBLE WASHED STONE 4' MIN. " ALL AROUND PRECAST STRUCTURES (3) UNITS REpUIRED 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 33.50, X 12.83, COMPACTION. (15.221 [2]) - 3•s'** 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED (1.5 % SLOPE) ( 1 % SLOPE) + WITHOUT INSPECTION BY BOARD OF HEALTH AND PERMISSION LOCUS MAP FOUNDATION- EXIST. SEPTIC TANK 92' LEACHING o OBTAINED FROM BOARD OF HEALTH. D' BOX 12' FACILITY 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING NOT TO SCALE 42.3' BOTTOM TH-1 ASSESSORS MAP 165 PARCEL 48 *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL **INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT (G=W EXPECTED AT DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS 1000 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE ELEV. 5t' PER TOWN MAP) OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR TO PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE COMMENCEMENT OF WORK. CONDITIONS IF NOT SUITABLE 11. EXISTING LEACHING FACILITY SHALL BE PUMPED AND VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. IMMEDIATELY GRANTED BY THE BOARD OF HEALTH AGENT OR PROVIDE 38' OF BY HEALTH INSPECTOR 40 51L LINER SAS 12. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE PAPERWORK AND HEARING REDUCTION PROPOSALS APPROVED IN AREA SHOWN REMOVED 5 BENEATH AND AROUND THE PROPOSED BY THE BOARD OF HEALTH REVISED DURING A PUBLIC TOP AT EL. LEACHING FACILITY. HEARING HELD ON AUG. 4, 2009 48.9', BOTTOM 2) FAILED SYSTEMS ONLY - SEPTIC SYSTEM COMPONENT TO AT EL. 44.9't SYSTEM DESIGN. FOUNDATION SETBACK, IF AN IMPERVIOUS LINER IS DESIGNED AND INSTALLED (10' OR GREATER ALLOWED). �7 GARBAGE DISPOSER IS NOT ALLOWED 3) FAILED SYSTEMS ONLY - SOIL ABSORPTION SYSTEM / L .36 INSTALLATIONS PROPOSED MORE THAN THREE FEET BELOW / G ��' CAU710N: GASUNE DESIGN FLOW: 4 BEDROOMS 0 110 GPD = 440 GPD GRADE WITH PROPER VENTING (PIPED TO THE ATMOSPHERE) F` - AND WITH H-20 LOADING, BUT IN NO CASE SHALL THE SAS / \9� 1 USE A 440 GPD DESIGN FLOW BE LOCATED MORE THAN SIX FEET BELOW GRADE. 100 00, - 6p\ 52.39 SEPTIC TANK: 440 GPD (2) = 880 15.405 (1) (h): WATERLINE TO ,BE LESS THAN 10' TO PROP. SAS / 52343 **RE-USE EXISTING 1500 GAL. SEPTIC TANK (SLEEVING OF WATERLINE PROPOSED) / cn LOT 47. 1_G 5' -.3 10,506# S.F. _ / .41 ■ LEACHING: TEST HOLE LOGS ; 5 3 4 52.3 O EXIST. ST** SIDES: 2 (33.5 + 12.83) 2 (.74) = 185 GPD BENCH MARK - END OF BRICK WALK / 52.40 0 \ BOTTOM 33.5 x 12.83 .74 = 318 GPD ENGINEER: DANIEL E. GONSALVES, SE #13587 AT STEP OF LANDING ELEV. = 52.4 / x 5 8 .85 ° \ O ) / r /WITNESS: DON DESMARAIS, IRS 52.1 1 " 2.83 Exlsr. TOTAL: 615 S.F. 455 GPD EXIST. DWELL. SUNRM. DATE: 3/12/13 / 52. A TOP FNDN. = ON ❑ USE (3) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) / 1�p_ ELEV. 52.85 POSTS WITH 4' STONE ALL AROUND (RATED H-20) i PERC. RATE _ < 2 MIN/INCH 52.07 (FULL FNDN.) PROP. VENT WITH CHARCOAL FILTER / I / \ AND BUGSCREEN (FINAL PLACEMENT BY / TH 6 0 CLASS I SOILS P 13881 CONTRACTOR WITH HOMEOWNER TH1 1 # F CONSULTATION) 1 FNDN. �- / 52 62 MA %RICK SLEEVE WATER N / W K 48 LINE WITHIN 10' 0 APPROVED DATE BOARD OF HEALTH ELEV. ELEV. / "o ° I OF SAS 52.66 52.56 ,0 0" 1 52.3' Q" 2 52.3' 52.20 A x 2'2 SLAB 52.56 14" 1 x .3 52.6 TITLE 5 SITE PLAN A A I ■ AK 10 "' 39 '15 5 SL SL I c�. 6P OF ' 49 52.39 10YR 3/2 10YR 3/2 152.23 21 52.51 52.49 12" 51.3' 12" 51.3' \ 14 K 0/ _0 GRAVEL \ -7 \\ a PARKING B B Y"52: 522.C4� 112 STURBRIDGE DRIVE LS LS > �Q , 30 „ 10YR 5/8 10YR 5/8 \� 51 a6 69 52` 52.46 OSTERVILLE 20 49.6' 22 49.5' ' o m 52.12 PREPARED FOR >�.78 3 �8 76.25' 84_ 52.02 BORTOLOTTI CONSTRUCTION/ PERC c C BEDENKOP _� - --x 52.13- Ms MS Sr""?8MOGE p R/VE DATE: MARCH 15, 2013 REV. 4/15/13 (FNDN LABELS) 2.5Y 7/4 2.5Y 7/4 . OF-'';�NA off 508-362-4541 ! IEI & o a y fax 508 362-9880 � C,��.,:�A. s .ram DANIEL Gs . OJA� "� A. m CI'JIL cn OJALA 120 42.3 120 42.3," No.46502 No.40900 down cape en gin eerin g, in c. � •, � NO GROUNDWATER ENCOUNTERED Scale: 1"= 20' )JAL -goyO' CIVIL ENGINEERS f /'2, - - 4�I� )�'�` LAND SURVEYORS 0 10 20 30 40 50 FEET DATE DANIEL A.. OJALA, P. P.L.S. 939 Main Street - YARMOU THPOR T, MASS. DCE #13-034 13-034 BORTOLOTTI_BEDENKOP.DWG