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Home My WebLink About0048 SUNSET LANE - Health 48 Sunset Lane Osterville . I., A= 1-17-113 i Commonwealth of Massachusetts l W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 48 Sunset Ln Property Address Cathy Clifford Owner Owner's Name information is required for every Osterville MA 02655 4-14-14 page. City/Town State, Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services ` Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number- B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: Passes ❑ Conditionally Passes , ❑.,Fails, 1EINeeds Fu � v luatio the Local Approving Authority 4-14-14 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 is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to.the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of.inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3f13 Title 5 Official Insp 'on orm:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 48 Sunset Ln Property Address Cathy Clifford Owner Owner's Name information is.required for every Osterville MA 02655 4-14-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts' W Title 5 Official Inspection -Form Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments . °M 48 Sunset Ln Property Address „ Cathy Clifford Owner Owner's Name • information is r Osterville MA 02655 4-14-14 wired for eve - e9 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) a ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): y ❑ 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): ❑ bro.ken pipe(s) are replaced ❑ Y' ❑ N ❑ ND (Explain below):. ❑ ` obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C). Further.Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. ' 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: r. ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or'privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 48 Sunset Ln Property Address Cathy Clifford Owner Owner's Name information is recuired for every Osterville MA 02655 4-14-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y 2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 48 Sunset Ln Property Address Cathy Clifford Owner Owner's Name - information is Osterville MA 02655 4-14-14 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ° Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool orprivy,is below high ground water elevation. : i j :i- 'lit ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well ❑ ® Any portion of a cesspool or,privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence' of ammonia nitrogen and nitrate nitrogen-is equal to or less than 5.ppm, provided that no other failure criteria are triggered.A copy of the analysis . and chain of custody must be attached to this form.] ❑ • ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either'yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area IWPA) or a mapped Zone Il of a public water supply well If you have'answered "yes"to,any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall,upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins r 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Sunset Ln Property Address Cathy Clifford Owner Owner's Name information is required for every Osterville MA 02655 4-14-14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping Information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan,at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) 310 CMR 15.302 5 PP P ) [ Ol D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form 4 Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments a'- 48 Sunset Ln Property Address' Cathy Clifford ' Owner Owner's Name information is required for every Osterville MA 02655 4-14-14 page. City/Town State Zip Code Date of Inspection D. System Information Description: P It Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection Yes ® No information in this report.) Laundry system inspected? .. �❑ Yes ® No Seasonal use? r ❑ Yes ® No Water,meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No L 4-2014ast date of occupancy: � .�� ,, , :; , , •�; � w , '" .'� pate 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? - El Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M0 48 Sunset Ln Property Address Cathy Clifford Owner Owner's Name information is required for every Osterville MA 02655 4-14-14 page_ City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner-- pumped 5-2013 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy El Shared system (yes or no) (if yes, attach previous in spection records, If any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f Commonwealth of Massachusetts ' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 48 Sunset Ln t Property Address Cathy Clifford Owner Owner's Name information is required for every Ostefville MA 02655 4-14-14 page. City/Town 'State, Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2003 • ' c Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): , 42" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): 36" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) f If tank is metali list age: years Is age•confirmed by,a Certificate of Compliance? (attach a copy,pf certificate) ❑ Yes ❑ No Dimensions: 1500 gal 1211 Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 48 Sunset Ln Property Address Cathy Clifford Owner Owner's Name information is required for every Ostefville MA 02655 4-14-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 48 Sunset Ln Property Address Cathy Clifford Owner Owner's Name information is required for every Osterville MA 02655 4-14-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped.at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No 'Alarm level: Alarm in vvorking order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of,alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �. 48 Sunset Ln M Property Address P Y Cathy Clifford Owner Owner's Name information is required for every Osterville MA 02655 4-14-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from chambers. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments VA °M 48 Sunset Ln Property Address Cathy Clifford Owner Owner's Name information is Osterville MA 02655 4-14-14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ 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.): Leach chambers in good condition and holding 2" of water with stain line at 6" off bottom of chamber. Cesspools (cesspool must be.pumped as part of inspection) (locate on site plan): Number and configuration r Depth—.top of liquid to inlet invert Depth of solids layer Depth of scum layer ► Dimensions of cesspool Materials of construction . Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 48 Sunset Ln Property Address Cathy Clifford Owner Owner's Name information is required for every Osterville MA 02655 4-14-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form _Not for Voluntary Assessments °M 48 Sunset Ln _ Property Address .4..;• Cathy Clifford r Owner Owner's Name information is required for every Osterville MA 02655 4-14-14 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately _ d a t5ins•3/13 s Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 48 Sunset Ln Property Address Cathy Clifford Owner Owner's Name information is required for every Ostefville MA 02655 4-14-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water v ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments_ 48 Sunset Ln Property Address Cathy Clifford Owner Owner's Name information is required for every Osterville MA 02655 4-14-14 page. City/Town state Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater, ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Yl: Commonwealth of Massachusetts U Title 5 Official Inspection Form =� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Sunset Lane Property Address Michael Hoar Owner Owner's Name information is Osterville MA September 26, 2009 required for every —p _ page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out forms A. General Information ,../� on the computer, f � / use only the tab 1. Inspector: 111 !!! key to move your cursor-do not Carmen E Shay use the return Name of Inspector - Y Shay Environmental Services, Inc. 110 rab Company Name 185 Ashumet Road Company Address ' NJ CA Mashpee MA 02649 '" City/Town State Zip Code Z 508-539-7966 3080 Telephone Number License Number p J= M B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑' Conditionally Passes. ❑ Fails ❑ Needs v at o the Local Approving Authority 9/17/09 Inspector's nature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. D 48 Sunset lane,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage posal System•Page 1 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Sunset Lane Property Address Michael Hoar Owner Owner's Name information is required for every Osterville MA September 26, 2009 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 22" effective depth availble per stain line. System passes. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) 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: ❑A 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 48 Sunset lane,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 2 of 15 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Sunset Lane Property Address Michael Hoar Owner Owner's Name information is required for every Osterville MA September 26, 2009 —_ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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:. C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 48 Sunset lane,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Sunset Lane Property Address Michael Hoar Owner Owner's Name information is Osterville MA September 26, 2009 required for every p page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z 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. 48 Sunset lane,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 n Commonwealth of Massachusetts h r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �a 48 Sunset Lane Property Address Michael Hoar Owner Owner's Name information is Osterville MA September 26, 2009 required for every p page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone 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. 411 Sunset lane,Osterville•031011 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M. 48 Sunset Lane Property Address Michael Hoar Owner Owner's Name information is required for every Osterville MA September 26, 2009 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ® ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The'size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(5)] 48 Sunset lane,Osterville•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ~ 48 Sunset Lane Property Address Michael Hoar Owner Owner's Name information is required for every Osterville MA September 26, 2009 page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): - Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 48 Sunset lane,Osterville•03/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 7 of 15 I ., Commonwealth of Massachusetts Title 5 Official Inspection Form JSubsurface Sewage Disposal System Form - Not for Voluntary Assessments a 0 48 Sunset Lane Property Address Michael Hoar Owner Owner's Name information is Osterville MA September 26, 2009 required for every P page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and-a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 11-27-02 - BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 48 Sunset lane,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �. � 48 Sunset Lane Property Address Michael Hoar Owner Owner's Name information is required for every ery P Ostille MA September 26, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks, plumbing properly vented Septic Tank (locate on site plan): Depth below grade: 6„ feet Material of construction: . ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age:" years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate)` ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 6' x 10' - 1500 gallon k _ _ Sludge depth: 16" Distance from top of sludge to botto of outlet tee or baffle' 15" m Scum thickness Distance from top of scum to top of outlet tee or baffle 4 Distance from bottom of scum to bottom of outlet tee or baffle 4 How were dimensions determined? Measured 48 Sunset lane,Osterville•03/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Via ^ 48 Sunset Lane Property Address Michael Hoar Owner Owner's Name information is required for every Clsterville MA September 26, 2009 - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition,lnlet Tee in good condition, outlet Tee in good condition - Recommend Pumping Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): 48 Sunset lane,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 1 F s • Commonwealth of Massachusetts _ Title 5 Official Inspection Form - J Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Sunset Lane Property Address Michael Hoar Owner Owner's Name T information is Osterville MA September 26, 2009 required for every _ —p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copyattached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert D-Box Present Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Liquid equal with outlet inverts. Two outlets present. D-Box is 4' Below Grade. No significant solids carry-over noted Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 48 Sunset lane,Osterville•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \a � 48 Sunset Lane Property Address Michael Hoar Owner Owner's Name information is required for every Osterville MA September 26, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1 -25' x 13' x 2' ❑ 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.): Inspection Installed. No Liquid in SAS - Stain Line @ 2". 22" effective depth availavble 48 Sunset lane,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Sunset Lane Property Address Michael Hoar Owner Owner's Name information is required for every Osterville MA September 26, 2009 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 48 Sunset lane,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11� - 48 Sunset Lane _ Property Address Michael Hoar Owner Owner's Name information is required for every Osterville _ MA _ _ September° ' 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 water supply enters the building. r cJ=r — t — \J06GA A J } Q 48 Sunset lane,0ster0le•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 t Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 48 Sunset Lane Property Address Michael Hoar Owner Owner's Name information is required for every Osterville MA September 26, 2009 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: No groundwater at 12' - per soil evealuation Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: refer to plans on file 48 Sunset lane,Osterville•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 35'-Orr X--9" 17'11" ' 13'-4" ,- T-6"x V-4" T-6"X'-4" Utilities � � N 6'-0"x6-6"sD o CV -a a 2r_ rr Office00 Playroom m x Finished space Finished space rn �' rn �' /[�— 5r-6" 2 -10" r 10" 19r 2rr ------------------------------- -------------------------- F . --------'--------------------•- -----' -------- 2 6" Y-0"x 6'4"CO 4'-8"x 6'-6"CO N Storage shelving HVAC *N Finished space ^' Laundry o � w s Unfinished space co k ca 0 ~ 30-Err TOW�Ii C}FBfSTABi.E, NUP slc Tax cAP� / SrU LEACl: 4G FAGIL , NO '�FBF�I)�IIOI�S M TDATE :i~C1R+11?I 11�NC `I3A Separation I3istance 3etween die: Maximum Adjusted odurater'T f to to tfie'Bottain of I aei ing FaG{ity Feee. PnYate�fifaier Suppty�4Te1i auedLeachm— ,Facility ('PY reIIs exist on site or,*m. sin.2t�feet of leaching f cjlicy} F t; Edge of�Aletlatid and Leaching l"�acility{If any wetlai� xi t -' Within-3t)O Eeei 41. hiitg fact� A} L _/ t Furnished by c5 /�vl o � OF ' D 0 c- 65— 3,2 � � w No. � � ��- � Fee ah .� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(ppricatiou for Zi5pogaf bpgtem Con5tructiou Perron Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 54%Sur Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,& tfflkTt NODOYLE ASSOC, 42 Canterbury bane �'f•�. L jG� t� ^�� East Falmouth, MA 02536 508/540-2534 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow '33.4 gallons per day. Calculated daily flow gallons. Plan Date 1 .• O—�Number of sheets Revision Date Title Size of Septic Tank X 5_^0 Type of S.A.S. cAi^Mj3LjL Ta3,1r�►t►�.Nr Description of Soil 5ra-3! �i.e� So►t_ L-.btrS 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 issue thi oard Health. Signed Date Application Approved b Date v Application Disapproved for the following reasons Permit No. Date Issued No. Fee �✓' GJ j/°' Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS ' PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZIppfication for Migool *pgtetn Construction i3ermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 418 SyN SL.r �� Owner's Name,Address and Tel.No. Assessor's Map/Parcel 0 G 2GE. Installer's Name,Address,and Tel.No. Designer's Name,Ads L I�jio. DOYLE & ASSOC. 42 Canterbury Lane J,or_ Odd TO y2�s—R�SS� �. East Falmouth, MA 02536 Type of Building: Dwelling r No.of Bedrooms Lot Size a(a8 sq. ft. Garbage Grinder( ) Other --f Type of Building No. dPersons Showers( ) Cafeteria( ) Other Fixtures fM Design Flow 3 3 gallons per day. Calculated daily flow 3 3L7 gallons. Plan Date 1J oV• 14�, D ► Number of sheets Revision Date Title 5tr_v.1A. TZra^\7, FLA Z=om At Sum sr i 1._x%ac= Size of Septic Tank b 1 Type of S.A.S. c-uA,r\fsf_TL 'RrsvALA+ '' ` Description of Soil S r P_ 5\Z'S= r SS>�L �--•ct S t Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: 2 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 y thi Board o Health. �-, Signed Date__3 Application Approved b / if Date Application Disapproved for the following reasons /� V i I Permit No. } Date Issued `. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )'Repaired ( )Upgraded( ) •.'. Abandoned( )by"I - �• pl,4 L 7-0 at Ll S t///SET G.,1rVt' Qua%��'/ALE has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NQ,d?��3�,._711 ated ��" eC'��3 J Y Installer 4r. C. �4 L T U Designer 17'e99Vr N DOA-1 The issuance of this permit shall not be construed as a guarantee that the syst will function a designed Date I i I�'� D Inspector �_� No. C��/ � Fee / 42� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS li6po5af *pgtem Construction Vermit . Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at y SS S�//✓SE T L•9�✓F O S Tt—icw/l!E' t Q' 3. and as,described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply`with Title 5 and the following local provisions or special conditions. ` ''Provided:Construction must be completed within three years of the date of thisip rmit. m Date: - k� - Approved by TOWN OF BARNSTABLE �� S��Ss°� �� ®® i LOCATION SEWAGE #/ VILLAGE �Sf�ry� `/� ASSESSOR'S MAP & LOT�f7��3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) ��''/.3 •N'� NO.OF BEDROOMS A BUILDER OR OWNER i PERMIT DATE: 3��G"® 2- COMPLIANCE DATE: I d 7 �Z Sepafation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet E 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 I Furnished by I - ti 13 43 � ® a �- a. 93' 31(l, , 3 3 0 TOWN OF BARNSTABLE IC(,f ATION 46 SEWAGE#�)QQ 61ILLAGE Le ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. Zdnr., SEPTIC TANK CAPACITY I'Sao Gc.\ LEACHING FACILITY:(type) cA (size) NO.OF BEDROOMS OWNER N�,ce�ei PERMIT DATE: COMPLIANCE DATE:J'1� O 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) N 64 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 4 Feet FURNISHED BY (S is 1 , ET lii�L% 'S. � TOWN OF BARNSTABLE L D P /Oh/03 L0,CATION le ASSESSOR'S Leh SEWAGE # ?Oo�� 733 VIL AGE �sf�r� r !le ASSESSOR'S MAP & LOT//7///3 INSTALLER'S NAME&PHONE NO. j0kn SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS 1 BUILDER OR OWNERS PERMITDATE: 3'�G"off COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 13 W r L 3 g95-' f� 1 - o 0 C�p (D 'S' C1 �e �ca qe <` T, . S<l Pond 0g, _ - EACH Qa S w TOP FOUND. EL >, ., _ s rowN S% , 6.• �I 8 43 4 _ —, _ 2 of 1/B 1/2 Peastone - R (�..�,. ,TA.x..Cov�vc__ta�/ cz.';:.5�{SCM_._Gr:+t.+�t'nNrala<<✓ �-- q m La C. nHILLSIDE m �. ! S F T� S C� t tZ C.5'p • y s y � ` ST o by � h a. ). . ( : - - �3.� OS ERVILtE _ East _ . . INV. EL �p >✓x�� Trench Width � d � Locu --wntElt TIGHT COVER , s ,r—�--- Bay Mashed s ed Stone 314 1 12 Wa d Cru y �.ow LINE, / / qa Pn 10 MIN. _ � 2 LEVEL - • - wv PROPOSED S.A. S. TRENCH SECTION �. � Rd i ELF..$ �--- - ..._..� PR 4 °� TOWN o _. d Ai t �, N � �. LANDING 10' MIN. ; m Ave V �� 4 UOUIO DEPTH m , MIN. s — - __ Total Trench LB z�. - SUMP INV. EL 3`(,1 3/4 — 1-1/2 ➢Meshed Crushed Stone _....... �._. . _ _ INV. EL. INV. EL ��-. . I • •. `.�-..per, •�. o ao o C= r 1500 GALLON PRECAST REINFORCED CONCRETE SEPTIC TANK 1rnY El. 3t,.o o El >✓L.-3�.e c� PRECAST REINFORCED CONCRETE MINIMUM CONSTRUCTION MATERIALS PER 310CMR 15.226(2 DISTRIBUTION BOX No. of Trenches t TEES SHALL BE CONSTRUCTED OF ,SCHEDULE 40 PVC AND t' SHALL EXTEND A MINIMUM OF 6" ABOVE THE FLOW LINE INSTALL ON A LEVEL BASE No. of 600 Gallon Precast Chambers Z 5 OF THE 'SEPTIC TANK AND BE ON THE CENTERLINE OF THE " n n MINIMUM WALL`THICKNESS - 2 SEPTIC TANK LOCATED, DIRECTLY UNDER THE CLEAN=OUT 3�4 - 1-1/2 Mashed Crushed Stone MANHOLE. MINIMUM INSIDE DIMENSION 12 , E'l zq A THE INLET PIPE ELEVATION SHAD.,BE NO LESS THAN 2- 'NOR- OUTLET INVERTS SHALL BE EQUAL TO EACH ---_Abe. Nx.�t� t�oulrTr�A~�n I MORE THAN 3" ABOVE THE INVERT ELEVATION OF THE OTHER .AND AT 2` MIN IMUM MUM BELOW INLET INVERT. S84 ti OUTLET PIPE. - - - - -113 - - - E I . THE DISTRIBUTION LINES FROM .THE DISTRIBUTION BOX 49.t g SHALL ALL HAVE EQUAL INVERTS AS DETERMINED BY FLOODING t SEPTIC TANK.SHALL BE INSTALLED LEVEL..AND TRUE TO GRADE ODING .� ON A LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY THE DISTRIBUTION BOX TO .THE HEIGHT OF .THE DISTRIBUTION 39 „ LINE INVERT AFTER ALL LINES HAVE BEEN SEALED IN PLACE. •" O COMPACTED AND ON TO WHICH SIX 'INCHES OF CRUSHED STONE \ ti 1 INVERT.ADJUSTMENTS SHALL.BE MADE BY FILLING WITH DURABLE 1 � '•. \ -- -- ` HAS BEEN .PLACED TO ENSURE STABILITY AND 70 PREVENT � SETTLING, AND NON-DEFORMABLE MATERIAL PERMANENTLY TL FASTEND TO THE � • LINE OR RECONSTRUCTING THE LINES UNTIL AL 5,0 ' L INVERTS ARE OF �•�...' SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9". EQUAL ELEVATION: Remove Cone. Patio i a i THREE 20- MANHOLES WITH READILY REMOVABLE IMPERMEABLE , .COVERS OF DURABLE MATERIALSHALL BE VI PROVIDED WITH-ACCESS_ PORTS BEING PLACED AT THE CENTER AND OVER THE INLET AND 1 35. 9 `y ,,,: u'y OUTLET .TEES. 1 yMh . �emave Shed THE OUTLET TEE SHALL BE EQUIPPED. WITH GAS BAFFLE. � , 40 Remove existin cesspool E � , �• P Proposed SAS and all contaminated soils , YW with clean course sand. f 1112. 7' .,•db O �� 1 '- Proposed 1500 Gallon Tank - DESIGN DATA: o 41 STRUCTURE TYPE NO. BEDROOMS GARBAGE 1 .DISPOSAL., Q, , DESIGN FLOW Cre fvl > � �•.�. Space - Exist. Deck GRAPHIC SCALE 41 SEPTIC TANK 10 c S 10 20 _ - usr'_ 00 ru4 _ . : Zoning district: RC Z ing LEACHING FACILITY r t`3 -r -4.N-" -r a-� -7- C. , f �' Z 6 T--- ��-- ( fit h'1♦�ET ) ,' � Building setbacks• 1 inch 10 ft" KS11S , 'tip �, ; ►�. �s'� ,p �t U 44� F�•Ont-20 - Side & Rear--10 PLAN PYEW \ ,� ' �cstA.L, -�hc�s_�ct.��r,u.l 1 •b 42 , Assessors 'Map. 1171113 0 , � I ti FM Data: Zone C I � FIRM Panel. 250001 0016 D r Panel Rev: Date: July 2, 1992 SOIL OBSERVATION DATA: .TEST DATE {1- t3 -o, L 0T I w , o ; General Construction Notes � S T�nyut� q. , 42 SOIL EVALUATOR B.O.H. AGENT tZ 1. , All the workmanship and materials shall conform to D.E.P. Title 5 and the Town of Barnstable rules and regulations for the subsurface disposal of sews + , T EXCAVATOP. �,.�-o g" p g 41.87 Sewage S stem Repair .Flan PERw �' Y .p` , Pre ared Far 2. At least one acres ort over tank tees shall b a 58475 4 ' . + P `' p e ccessible within 6 inches of finish grade, I 0 E with an remaining access its brought , Y g Po to within 12 inches of finish grade.' 40 i �� 4- 8 ,,'�� U �S o +� �c� .22 � I 1 41 , In _ d 3. All components of the sanitary system shall be capable of withstandm I-1-10 loading to fC Y Z _ 1 - ' , � � A s� y / unless they are under or within 10 feet of drives or parking. H 20 loading shall be used ____ wso Os terv111e Ilia ssa ch use t is under or within 10 feet of drives or arkin unless n � . I parking noted. 38.68 �s 10-m a/(, I 40.00 Sosle. 1 � 10 Date: No rember-15, 200,t - . • 4. The excavator/contractor shall verify the location of all site utilities prior to any Prepared By: - 3-t�E excavattan. Stephen J. Doyle And Associates � . • y 42 Canterburq Lane, E. Falmouth MA 02536 sAH� `�•S� _ Telephone: 508'540--2534 /� Qom_.J / 5. Sewer pipes shall be 4 inch Schedule 40 PVC lard at 0.02 slope. ET . P � • - * 6. An mason units,used to bring covers to de shall P ��jN F Mq Y masonry g grade 11 be mortared in place. ' . 1� `N-0F 'f4 tit s'rq It FF• . SS Gi51ER �' ,.. Ar,7 `s ° STEPHEN GN 1�:LLI G 7. Finish grade shall have a minimum slope of 0.02 feet per foot. Mr AN � R � J. ` r.'J. 23971 DOYLE 4a " No.37559 f�E•: E $t0 Q` V� •�.' p SUS rrAA V� DESC IP.�70N BY NO. DATE R