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HomeMy WebLinkAbout0193 STURBRIDGE DRIVE - Health 193 Sturbridge Drive Osterville F/R A = 166 096 v 1 I i I i F i (0(0- 0 /(p Commonwealth of Massachusetts �d Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Sturbridge Drive Property Address Bill Eudailey -` Owner Owner's Name information is Osterville ✓ Ma 02655 3-4-2020 required for every page. City/Town State Zip Code, Date of Inspection rt 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 /c f c13D on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return key. Company Name 374 Route.130 r Company Address Sandwich Ma 02563 City/Town State Zip Code rtscrnt (508)477-0653 S113747 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 4 , 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey Digitally signed by Brea Hickey - _ °Date:2020.03.1113:57:25-04'00' 3-4-2020 Inspector'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.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 } c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Sturbridge Drive Property Address Bill Eudailey Owner Owner's Name information is Osterville Ma 02655 3-4-2020 required for every City/Town/Town State Zip Code Date of Inspection page. Y P P C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System-Passes: ` ' I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 t c Commonwealth of Massachusetts _ - �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Sturbridge Drive v Property Address Bill Eudailey Owner Owner's Name information is required for every Osterville F Ma 02655 3-4-2020 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 E] 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 n Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Sturbridge Drive v- Property Address Bill Eudailey Owner Owner's Name information is Osterville Ma 02655 3-4-2020 required for every 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. i ❑ 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 ` El Backup of sewage into facility or system component due to overloaded or El clogged SAS or cesspool ❑ O 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 l� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Sturbridge Drive Property Address , Bill Eudailey Owner Owner's Name information is required for every Osterville Ma 02655 3-4-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont:) Yes No ' ❑ a Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ a Liquid depth in cesspool is less than 6" below invert or available volume is less than '/Z day flow ❑ El Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E] Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ O Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ El Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ E The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. . • I ❑ E 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 El El Area—IWPA) or a mapped Zone II of a public water supply well 6 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 6 / 193 Sturbridge Drive u� Property Address Bill Eudailey Owner Owner's Name info-mation is Osterville Ma 02655 3-4-2020 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 ❑ El Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? 0 ❑ Has the system received normal flows in the previous two week period? ❑ a Have large volumes of water been introduced to the system recently or as part of this inspection? Q ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ E] Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? t 0 '❑ Were all system components, excluding the SAS, located on site? 0 ❑ 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: El ❑ 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ 193 Sturbridge Drive v Property Address Bill Eudailey Owner Owner's Name information is Osterville Ma 02655 3-4-2020 required for every page. City/Town State Zip Code Date of Inspection M System Information 1 -Residential Flow Conditions: ° 4 4 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 462/GPD • '6 Description: ' Number of current residents: Does residence have a garbage grinder? Yes No Does residence have a water treatment unit? ❑ Yes 0 No Y 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 F!] No Seasonaluse? ❑ Yes [E No See below Water meter readings, if available(last 2 years usage (gpd)): Detail: 2019- 17,000gallons 2020- 21,000g6llons Sump pump? ❑ Yes ❑■ No " current Last date of occupancy: Date q - t5insp.doc•rev.7126P2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 t , Z, Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, f; 193 Sturbridge Drive Property Address Bill Eudailey Owner Owner's Name information is Osterville Ma 02655 3-4-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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: Owner- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes 0 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 Commonwealth of Massachusetts �n Title 5 Official Inspection Form - P Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Sturbridge Drive v Property Address , Bill Eudailey Owner Owner's Name information is Osterville t, Ma 02655 3-4-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 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: 2003 per plans Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 21611 Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 cam, Commonwealth of Massachusetts i ,�p Title 5 Official Inspection Form ; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Sturbridge Drive u Property Address Bill Eudailey Owner Owner's Name information is Osterville Ma 02655 3-4-2020 rec uired for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 1'6" Depth below grade: feet Material of construction: 0 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 1 Dimensions: 000galIons 2111 Sludge depth: 3411 Distance from top of sludge to bottom of outlet tee or baffle 0„ Scum thickness Distance from top of scum to top of outlet tee or baffle NS NS Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 c Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Sturbridge Drive Property Address Bill Eudailey Owner Owner's Name information is Osterville Ma 02655 d required for every 3-4-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): t NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass . ❑ polyethylene ❑other(explain): F 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 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): w NA 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 •a c!,, Commonwealth of Massachusetts Title 5 Official Inspection Form w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Sturbridge Drive Property Address Bill Eudailey Owner Owner's Name information is Osterville Ma 02655 3-4-2020 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): Orr 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.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts r �T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Sturbridge Drive u Property Address Bill Eudailey Owner Owner's Name information is Osterville Ma 02655 3-4-2020 required for every 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.): NA f * 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: . ❑ leaching galleries number: ❑ leaching trenches number, length: (5)hi cap infiltrators 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 c Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Sturbridge Drive Property Address Bill Eudailey Cwner Owner's Name irformation is Osterville Ma 02655 3-4-2020 required for every page. City/Town 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.): The SAS was in working order at the time of inspection. Leaching was dry when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA 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, I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 193 Sturbridge Drive V Property Address Bill Eudailey Owner Owner's Name information is required for every Osterville Ma 02655 3-4-2020 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) - 13. Privy(locate on site plan): Materials of construction: NA , Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): r y t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 193 Sturbridge Drive u% Property Address Bill Eudailey Owner Owner's Name information is Osterville Ma 02655 3-4-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 0 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 WS6 Ao A ANC' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �s ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I; 193 Sturbridge Drive Property Address Bill Eudailey ' Owner Owner's Name ' information is Osterville Ma 02655 3-4-2020 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) r 15. Site Exam: R Check Slope Y ❑■ Surface water , R Check cellar ❑� Shallow wells Estimated depth to high groundwater: ' No GW @ 144" 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: 6-10-2003Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: • r ❑ Checked with local excavators, installers (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file at the local Board of Health was used to determine high groundwater. 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 x� ,,p Title 5 Official Inspection Fora ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 193 Sturbridge Drive Property Address Bill Eudailey Owner Owner's Name information is Osterville Ma 02655 3-4-2020 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 W■ 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 i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 f� • RECEIVED DATE :_ 4,9103____ PROPERTY ADDRESS:_ 1 93 Sturbridge Drive-- APR 2 7 2003 Osterville TOWN OF BARNSTABLE ___ ___________ HEALTH DEPT. 1 - Masi 02655 ----------------------- On the above date, I inspected the septic system at the above address. This system consists of the following: 1 -1000 gallon septic tank 1 -1 000 gallon leaching pit. FAILED INSPECTION Based on my inspection, I certify the following conditions: 1 . This is a title five septic system. ( 78 Code) 2 . The septic system is in hydraulic failure. 3 . A new leaching area needs to be installed. 4 . The septic system is presently full. 5. The system should be pumped. SIGNATUR Name : - J__ P . _Macom6er_Jr Company :,�og�ph per_M��4m��r d_ Son, Inc . address :__�Qx ............ __(7ensery-LLLP—,_ Na__22-632-0066 Pnone : __508- 775_ 3338 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY LU P. MACOMBER & SON, INC. anks•CassPools LeachfleIdsPumpod & InstalledTown Sewer Connections 66 Centerville. MA 02632.0066 775.3338 775.6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:1 93 Sturbridge Drive Osterville Owner's Name: El i zah - h whitp Owner's Address: same Date of Inspection: 4/9/0 3 Name of Inspector: (please print) J.P. Macomber Jr. Company Name:Joseph P. Macomber & son Inc Mailing Address:Box 66 Centerville Telephone Number:508-775-3338 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 to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority &Fails Inspector's Signature:. /—/, Date: The system inspector shall ubmit 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 1 Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 193 Sturbridge Drive Osterville Owner: Elizabeth White Date of Inspection: 4/9/0 3 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section,D A. System Passes: f �� AM I have not found any inform which indicates that any of the failure criteria described in 310 CMR 15.303 or m 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The septic sp-ptic system is in hydraulic failure A new leaching ` area npprlc to hp installpd B. System Conditionally Passes: I-ld One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. AAQ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: &Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: t 2 Page 3 of I I OFFICIAL INSPECTION FORM • NOT FOR VOLUNTARY-ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ? Property Address: 1 Os ervi e Owoer: Elizabeth White Date of lospectioo: 4/9/03 C. Further Evaluation is Required by the Board of Health, Atd Conditions exist which require further evaluation by the Board of Health In order to determine if the system ' is railing to protect public health, safety or.the environment. I. S)stem will pass unless Board of Health determines In accordance with 310 CMR 15.303(l)(b) that the s,vstem is not functioning in a macoer wblch will protect public bealtb, safety and the environment: 4LO Cesspool or privy is within 50 feet of a surface water -, _ - Cesspool or privy is witbin s0 feet of a bordering vegetated wetland or a salt marsh 2. S,N stem will fail unless the Board of Health (and Public Water Supplier, if any) determines that the slIstem is functioning in a manner that protects the public health, safety and environment: AJO The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or rributary 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 1J0 The system has a septic tank and SAS and the SAS is within SO feet ore private water supply well. ,r The system has a septic tank and SAS and the SAS is less than 109 feet but S feet or more from a private eater supple well'• Method used to determine distance ��Lt '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 s ppm, provided that no other failure criteria are rriggered. A copy of the analysis must be anaehed to this form. ). Other: &AOL 3 Page 4 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 193 sturbridge Drive Osterville Owner: R] ;zabeth Wh; to Date of Inspection: 4/9/03 D. System Failure Criteria applicable to all systems: You must indicate yes"or"no"to each of the following for all inspections: Yes No ackup of sewage into facility or vs_ tem om onen ue to overloaded or clogged SAS or cesspool l7ischarge or ponding of effluent to the surface o 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 J-,�Q> , C. 7 _ �_ iquid depth intecspe9l s less than 6"below invert or available volume is less than 'i day flow equired 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. j Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t_ , ny portion of a cesspool or privy is within a Zone 1 of a public well: 1 , y portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma Gs (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 Plow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no� y the system is within 400 feet of a surface drinking water supply Zthe system is within 200 feet of a tributary to a surface drinking water supply. — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— IWPA)or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E 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 4 Page 5 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:1 93 sturbridge Drive r Osterville Owner: P1 i 7.ahPth White Date of Inspection: 4/9/o 3 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 t/ 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 ? Zwere 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? t 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 ? 4/he_ 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. Y — Determined in the field(if any of the failure criteria related to.Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)J 5 i Page 6 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 193 Sturbridge Drive Osterville Owner:F1 i zah h Whi te Date of Inspection: 4/9/0 3 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): Number of current residents:ate✓ � Does residence have a garbage grinder(yes or no): `.� Is laundry on a separate sewage system(yes or no):.wq [if yes separate inspection required] Laundry system inspected(yes or no): 45 Seasonal use: (yes or no):t Water meter readings, if available(last 2 years usage(gpd)): 2 0 01 —5 5, 0 0 0 gallons=1 5 0. 6 9 GP D Sump pump(yes or no): 4,0 2002-60, 000 gallons=1 64. 39 GPD Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): 4A gpd Basis of design flow(seats/persons/sgft,etc.): A)* Grease trap present(yes or no):.?1h 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: 41/1 OTHER(describe): AJf� GENERAL INFORMATION Pumping Records Source of information: None available Was system pumped as part of the inspection(yes or no): _D If yes, volume pumped: d gallons-- How was quantity pumped determined? "L> Reason for pumping: AA T� OF SYSTEM Septic tank,dam,soil absorption system /tl�Single cesspool ,C_Overflow cesspool ll6 Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) 42� Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) /t/d Tight tank A),If Attach a copy of the DEP approval yv Other(describe): Approximate ase of all compone ,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): -t& 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM INFORMATION(continued) Property Address:1 93 sturbridge Drive O� ryille Owner: Elizabeth White Date of Inspection: 4/9/0 3 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron Z40 PVC�D other(explain): Distance from private water supply well or suction line: Ad Comments(on condition of joints, venting,evidence of leakage, etc.): Joints appear ticrht No evidence of leakage The system is vented through the house vents . SEPTIC TANK: .,**"'(locate on site plan) 10W 0,40 .rJ5 Depth below grade: � Material of construction: �/concrete4l,�metaLf,,0 fiberglass4 dpolyethylene , �other(explain) //, If tank is metal list age:," Is age confirmed by a Certificate of Compliance(yes or no):o (attach a copy of certificate) Dimensions: Sludge depth: '�' Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: a - - 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.):. . Pump the septic tank annually, Garbage disposal is present Inlet and nutlet tees are in place The tank is structurally sound and shows no evidence of leakage. GREASE TRAI --�u/�locate on site plan) Depth below grade: 4/# Material of construction:A)0concrete„ meta LeAfiberglass4�±polyethylene fiP other (explain): iIJ� Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle:le Distance from bottom of scum to bottom of outlet tee or baffle: ,f/4 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.): Grease trap is not present. 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 193 Sturbridge Drive Osterville Owner:Elizabeth White Date of Inspection: 4/9/0 3 TIGHT or HOLDING TANM,/et/&(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete,&,J-metalLLt_fiberglass /�9 polyethylenes--other(explain): _ A2g Dimensions: Capacity: _____gallons Design Flow: gallons/day Alarm present(yes or no): z: Alarm level:_M Alarm in working order(yes or no):��i Date of last pumping: 64 Comments(condition of alarm and float switches,etc.): Tight nr holding tankg a'rP not nrPsent DISTRIBUTION BOX44v 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.): Di ct-ri hiit-i nn hnx is not j resent PUMP CHAMBER(locate on site plan.) Pumps in working order(yes or no): AAA Alarms in working order(yes or no): 10 Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Pump chamber is not present e t 8 .. Page 9 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Add ress:193 Sturbridge Drive Osterville Owner:F1 i .ab th White Date of Inspection: 4/q/n 3 SOIL ABSORPTION S STEM (SAS): (locate on site p n,excavation not required) If SAS not located explain why: Leeated• Seepage 19 TypV ,,-' leaching pits,number: .,)leaching chambers, number:f�_ leaching galleries,number: 0 leaching trenches,number, length: XM leaching fields,number,dimensions: 0 1' 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.): Loamy sand to boney sand to fine sand The leaching pit is in hydraulic ailure_ A new leaching area needs to be installed Soils are'' //damp.Vegetation is normal. CESSPOOLSreA,Y,(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Q Depth—top of liquid to inlet invert: Depth of solids layer: AIR Depth of scum laver: Dimensions of cesspool: lb 09 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.): Eesspeels are net present . PRIVy4�1L-(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.): Pri v)z i S not- prPSpnt q i Page 10 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 193 Sturbridge drive Osterville Owner:Elizabeth White Date of Inspection: 4/9/0 3 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public.tivater supply enters the building. 1 10 Page 11 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 193 Sturbridge Drive Osterville Owner:Elizabeth White Date of Inspection:4/9/03 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-if checked,date of design plan reviewed: NA Y1,3 Observed site(abutting property/observation hole within 150 feet of SAS) ND_Checked with local Board of Health-explain: NA yam_Checked with local excavators, installers-(attach documentation) yam_Accessed USGS database-explain:http // town.barnstable.ma.us. ` You must describe how you established the high ground water elevation: sed: Gahrety & Miller Model. 12/16/94 Ground water elevations above sea level. sed: USGS: Observation well data. June 1992 sed: USGS: Technical bulletin 92-000-1 Plate #2 Annual ranges of ground water �ley�,tions. January 1992 .Up U1 yr un Leaching Pit ;eet Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore,the vertical separation distance between the botto of the leaching pit and the adjusted groundwater table isd'Dr feet. 11 , WY) {••r•.rnrr '-Rtrr•rrsrn-mr•n1Rrs-rtn as+•rrr. r:•n+•r•.Tytr:�+fsnrm trsT•aa*+aT.Tcr.Htt v TOWN OF BARNSTABLE BOARD OF HEALTH F SUI)SURFACF SEWAGE DISPOSAL SYSTF,M INSPECTION FORM - PART D •- CERTIFICATION T:'t-r••.-•. t--.tir.�.-rr1fST+n'R.rrrl�uslrll�fnlrt•Ir'1*sTTtrmr-Tml+slnr R�R.RIt57w7vr� rsT ef•'mrnr�tO'•**rr+rrn•.:re•r•T•1. ._..� -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED f` STREET ADDRESS 193 Sturbridge Drive Osterville., ASSESSORS MAP, BLOCK AND PARCEL # 166-096 OWNER' s NAME Elizabeth ,White :' k PART D -• CERTIFICATION -I NAME OF INSPECTOR _ Joseph P Macomber Jr COMPANY NAME Joseph P. Macomber 9`Son Inc COMPANY ADDRESS Box 66 Centerville Ma • 02632 , Street Town or Clty State LIP COMPANY TELEPHONE ( 508 ) 775- = 3338 FAX ( 508 � 790 - 1578 n • CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposaj system at this address and that the information reported is true , accurate , and' omplete as of the time of -inspection , The inspection was performed and any recoinmendations regarding' upgrade , maintenance , and repair are consistent with my training and experience in the proper, function and maintenance of on 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 CMR 15 - 303 , Any failure criteria not evaluated are As stated in the. FAILURE CRITERIA section of this form , z System FA+ILE'll* The inspection w}licl► I have con acted has found' that the system fails to Protect the public heal�th' and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on- PART C - FAILURE CRITERIA of this inspection form . Inspector Signature JDate �/el-� ne copy of this c °ification must be provided to the OWNER, the BUYER ( where applicable and the DOARD OF HEALTH. * If the inspection FAILED, the owner or" perator shall u ` within one year of' the date of the inspection, unless allowed- ortreq'uiredm otherwise as provided in 3.10 CMR 16 . 305 . partd .doc .„ TOWN OF BARNSTAB_ LE LOCATION /9.� f'To�G'.fi6GC 4-If SEWAGE VILLAGE a fT ASSESSOR'S MAP&LOTS,<6"0 9� INSTALLER'S NAME&PHONE NO. cT/�-' fe-26oc22.�' 77T o 7 0 7 SEPTIC TANK CAPACITYs- LEACHING FACILITY: (type (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: °1 -I ' C 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 i within 300 feet of leaching facility) Feet Furnished by AD A Ado vSC A6: � ,6 p F G'G } G No. 16 �3✓ f� Fee 5©- /— THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 21ppYtcation for 30igaal 6pztem Con5truction Permit Application for a Permit to Construct( )Repairfe-J)Upgrade)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. I f-I,f T11ee&/�0C e AOA?r`e Owner's Name,Address and Tel.No. Assessor's Map/Parcel oa 0-�b Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �.� _2 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building ��'S' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �- gallons per day. Calculated daily flow gallons. Plan Date o<—%—o,f Number of sheets / Revision Date Title Size of Septic Tank /fed'/�� /�G cal- Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Si ed Date 7 �I'—off Application Approved by Date 7 1 t5 0 Application Disapproved for the following reasons Permit No. ' Date Issued 1 5�0 3 - --------------------------------------- Fee 0A / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes r PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,,MASSACHUSETTS f A ZippYication for Mioaal bpotem Conztrudion Permit Application for a Permit to Construct( )Repair C,,o Upgrade)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. l' Aop�r�` Owner's Name,Address and Tel.No. Assessor's Map/Parcel ✓� d 96 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Silk G �`G�oE!/f 7 ,S o) Type of Building: Dwelling No.of Bedrooms Lot Size'."— -----.sq.ft. Garbage Grinder( ) Other Type of Building ��`t' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow � gallons per day. Calculated daily flow yo gallons. Plan Date /P -off Number of sheets Revision Date Title Size of Septic Tank �-x�O�/G� /oG o �!1 Type of S.A.S.,of--Yk o Description of Soil e Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and)not'lto plact'�Phe system in operation'tintil a Certifi- cate of Compliance has been issued by this Board of Health. , Si ed Date Application Approved b Date 7 —�7J/�-0a3 Application Disapproved for the following reasons Permit No. 3 3 Y Date Issued :;2A 15 o 3 ---------------------------------------- - - - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( _)_Repaired (�UpgradedX) Abandoned( )by A* at /9 .7 J,710"?(7"e./.O f<-1 ,pit. oJ''T. has been constructedf in a cordance with the provisions of Title 5 and the for Disposal System Construction Permit No.2DC 3- 3/� dated 3 Installer t_3/Ai. ZF e9oEj�' Designer The issuance of �'s p 'rmit shall not be construed as a guarantee that the system �6*A r� Date At(, 3 Inspector No. O� 3 — —i --------------------------Fee S C� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ig0$ar *p5tem COn$truction Permit Permission is hereby granted to Construct( )Repair;()Upgrad?,-� )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special condition . Provided:Construc ion tjust be completed within three years of the date o th'r p t. Date:_. /f 3 U 3 Approved by T ASSESSORS 'MAP : TEST HOLELOGS- PARCEL : SO I L EVALUATOR 1 �I D ' 1M��J�^f C Le FLOOD ZONE: NOTES: � > �L�G! ! _ c5� REFERENCE: WITNESS : 1► Q1 t7 . 'V --- - DATE: p V a 75 PERCOLATION RATE:,4 O 1 The installation shall comply with Title V N VVI ?/�✓ •� 1 ) P Y and Town of Barnstable Board of _ ?fix ..-_--. `_ — 4 Health Regulations. -j, �' - 2) The installer shall verify the location of utilities, sewer inverts and septic /[ � 'G �i—�(^j� Lllkt L T,/ ---- TH- 1 TH-2 components prior to installation. ��,( (�,.�( � l 5 i 4 Z� 3 All septic piping to be 4 inch Sch 40 PVC at 1/8" _ _ ! - " -`1 - �. ",�.- ) P P P g per foot. (� 4) Existing leach pits to be pumped and backfilled per Title V abandonment tttAM 5 p%4p Procedures. 5) This plan is not to be utilized for property line determination nor any other ` — purpose other than the proposed system installation. LOCAT I ON MAP C�Th' ) ` 6) All septic components must meet Title V specifications. 7) Parking shall not be constructed over 1110 septic components. C 5 8) The property is bounded by property corners and property lines as depicted. 1l� 9) The property owner shall review design considerations to approve of total number of bedrooms to be considered for design. Receipt of payment for the plan and -r n lD installation based on the plan shall be deemed approval of the number of bedrooms. 'a y0 b -3 �C�._A�..._.___,____-- L 10)Existing tank to be utilized if the tank is a minimum of 1000 gallons. Size is to be verified at time of installation. If less than 1000 gallons a 1500 gallon tank is to be installed. SEPT I C'. SYSTEM DESIGN VA FLOW ESTIMATE 4—BE[iROOMS AT l io GAL/DAY/BEDROOM - �� GAL/DAY 0 U SEPTIC TANK r 9 � O o h GAL/DAY x 2 DAYS - GAL USE IDDD GALLON SEPTIC TANK qtft1Wv4Aff 01 L ABSORPTION SYSTEM r( ! ! t N b N Iernt? J M y S1DE AREA: 2.-�e L"; -1- ����J ------ BOTTOM AREA: , X �6 P a _ PT I C, SYSTEM SECT I ON (i►.�,T',S> w ? ) / tbw11�I, tMlA�, ►rfU uAse i�. 1 �Ll Yr b r h 11 -)GAL �7�qj b e A1- 473. IN � SEPT C T i o`� 3 JL .. rL OF ...- •ram � v SITE AND SEWAGE PLAN y' slow i P I ON : 0 I ( �L.tf00- Yr/ T '� 'e �I PREPARED FOR SAIL -�Wdj P ti a ° SCALE: 7 �,- - DAV I D B . MASON 9R ) DATE: 10 DBC ENVIRONMENTAL DESIGNS EAST SANDWICH . MA DATE HEALTH AGENT ( 5O8 ) 833- 2 177 W Z