HomeMy WebLinkAbout0012 TANGLEWOOD DRIVE - Health e
12 Tanglewood Drive
* u Osterville P r,4
12.1 056
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TOWN.OF BARNSTABLE C-1°
' LOC i;TION Dr SEWAGE # 2006-.fla
VILLAGE ASSESSOR'S MAP & LOT
INSTALLERS NAME&.PHONE NO. . < `
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) t.L f't �l I ��CA ize)
NO.OF BEDROOMS
BUILDER OR OWNER'
PERMTTDATE: .� 00 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater'Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility,r(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
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E No. Fee G
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Ts
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
i
.. . .. . . 01pprication for, Ziopogar *pgtem Congtruction Permit
Application for a Pe o ct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
744
Location Address or of No. ( 4 il�,c. p� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel '
.. �' v
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
. llc:�e t _Qe:%
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 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) C,.d G
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 y Board of Health. ^ �O
SignedA Date
Application Approved b Date
Application Disapproved for the following reasons
Permit No. Date Issued z5i �,?�y
Fee' �r
THE COMMONWEALTH OF MASSAC"USETTS Entered in computer:
s
°PUBLIC HEALTH DIVISION - TOWN OF BARNSTAB E.,MASSACHUSETTS
Yication for igogaYp6tern Cog, ,.uctionertnit
Application for a Permit to Construct( )Repair(,,, )Upgrade( )Abandon( ) s ,ompl ete System ❑Individual Components
Location Address or Lot No.4fJ r It ,—. b Owner's Name,Address and Tel.No.
Assessor's Ma /Parcel
p a- I - (75 -5 y ��..
Installer's Name,Address,and Tel.No. lr Designer's Name,Address and Tel.No.
r n.
Type of Building:
Dwelling No.of Bedroo 's r of S. sq. ft. Garbage Grinder( )
Other Type of Buildi'g S No. of ons Showers( ) Cafeteria( )
Other Fixtures
Design Flow `. fit'' gallons per day. Calculated daily flow gallons.
Plan Date �* .x Number of sheets Revision Date
Title f
i
Size of SeptidTank Type of S.A.S.
Description oflk
Nature R pairs or Altera'tio s(Answer then applicable)
Ci� G
�
Date last inspected: I
Agreement: ,
The undersigned agrees to ensure the const41\iori and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of t 'Rfl;vironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu by is Bo of"Health.
Signe Date '�'_ T
Application Approved Date s'
Application Disapproved for the follow ir +r asons
Permit No. " .� Date Issued
-------------- ---------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CE� that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( )
Abandonc4( )by /
at �'t '�`t �-'�Ga has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Pe . R Ms� datedO-' �'"
Installer Designer n A2(
The issuance of p t shall t be construed as a guarantee that the s to ion s dgne,
Date Inspector - r" �' 44?,
Co) f I'
No--- ------------------------ ---
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS
lwiopogal *p!tem Construction Permit
Permission is hereby pnted to Construct( )Repair )Upgrade )Ab don( )
System located at �� '' c- tiGb�
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 mus a completed within three years of the date of tlrmit. s ,
Date: •— r Approved s? k Fr y
r ,
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed `
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED.?1,A S)
1, J .
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=t ���-/` , hereby certify that the application for disposal works
pp. P
construction permit signed by me dated 3— S ^ C , concerning the
property located at 1�� Wf'rq® � �neets all of the
following criteria:
• This failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
'The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 feet of the proposed septic stem
P P P Y
Y
There are no private wells within 150 feet of the proposed septic system
o
/There is no increase m flow and/or change m use proposed
• ere are no variances requested or needed.
The bottom of the proposed leaching facility will not be located less than five feet above the maximum
a ' sted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when
plicable]
If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) 3
B) G.W. Elevation +the MAX.High G.W.Adjustment. _
DIFFERENCE BETWEEN A and B `
SIGNED : (AA�A DATE: f—
[Please SketA propo d plan of sys m on back].
NOTICE
Based upon the above information,a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
q:health folder:cert
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Stanton, David
To: jeffluff@comcast.net
Subject: Massive retention pond and septic issues at 12 Tanglewood Drive, Osterville
Good Morning Jeff,
On May 16th I was driving along rt. 28 and was stopped by a State Trooper to allow a dump truck to pull out onto rt. 28 at
the intersection of Rt. 28 and Tanglewood in Osterville. While waiting, I notice major work going on at your property
located at 12 Tanglewood Drive, Osterville. I was not sure what was going on, but I did notice a DOT truck, excavator,
backhoe and some large drainage pipes in said area.
When I got to the office that morning, I looked up the property information which shows that there is a 70'wide drainage
easement from Rt. 28 heading towards your house. I was very concerned because it appears that the leaching trench of
the septic system is located underneath where all this construction was going on. I spoke with the Health Director,
Thomas McKean, and another Inspector, Donald Desmarais, about the concerns. Inspector Desmarais and myself
gathered the information in the file and went to said location.
When we arrived, we spoke with the Mass DOT employee onsite and expressed our concerns about all the work in what
appears to be over(or very close)to the septic system. He explained the State has a drainage easement and we agreed
that there was an easement shown on the septic design plans, permit#87-433, issued on July 6, 1987. He showed us
where they had surveyed and marked the easement on the lot. On the West side of the lot, the easement goes to
approximately the midpoint of the driveway and runs parallel with Route 28 to the property line on the East side (which
lines up closely in reference with the abutting neighbors septic vent in the front yard.)
Based upon all the information submitted to the Health Division by septic installers and septic inspectors, it appears that
the septic system for your house is located in the drainage easement. According to the records submitted to the Health
Division, there is a leaching trench that is 11'wide by 33' long located beyond the lower landing of the stairs in the yard
going downhill towards Rt. 28. According to the Mass DOT employee, they are installing a large drainage pond and
drywells in the drainage easement. They are redirecting all the existing rt. 28 catch basins in this area to this new drainage
pond they are creating. I have not observed the plans from Mass DOT, however, I assume you would be able to obtain a
copy of the plans or be able to view them from Mass DOT.
310 CMR 15.000 (aka Title V) creates minimum setbacks for septic systems to various locations, including drainage
systems for the protection of the septic system, as well as the protection of public health. There are also maximum
coverage regulations for the amount of soil over the top of septic system components as well, which appears to also be in
violation of Title V. With it appearing that the septic system is located within the drainage easement and\or within 25' of
the drainage easement, and\or exceeding the maximum coverage over the top of a septic system component, which is in
violation of Title V, it is STRONGLY SUGGESTED that you take action to correct this situation as soon as possible.
Should you have any questions or concerns, please feel free to contact me.
Thanks,
David W. Stanton, RS
Health Inspector
Town of Barnstable
200 Main Street
Hyannis, MA 02601
Direct phone: (508) 862-4647
Health Dept. phone: (508) 862-4644
Health Dept. fax (508) 790-6304
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1
h _ TOWN OF BARNSTABLE
LOCATION _( � Q h I w0 U D'r SEWAGE # 200 G- sz�
VILLAGE_ ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. A,-�_
SEPTIC TANK CAPA CITY 0
C� _
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LEACHING FACILITY: (type) — �"� �,'t- �1 L✓ ! 56�. ize) ( —�
NO: K
OF BEDROOMS l `� � ��.'•
BUILDER OR OWNER C�ru C1 w
PERMITDATE:
COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within.200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
I within 300 feet of leaching facility) Feet
Furnished by
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Town of Barnstable Geographic Information System May 17,2013
121013
#2811
M
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121077
121056
#12
121012002
#2751
121057
#46
DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:121 Parcel:056 N
boundary determination or regulatory interpretation. Enlargements beyond a scale of Selected Parcel
Owner:LUFF,JEFFREY P Total Assessed Value:$291900
1"=100 may not meet established map accuracy standards. The parcel lines on this map w- �E
are only graphic representations of Assessor's tax parcels. They are not true property Co-Owner: Acreage:0.48 acres Abutters
boundaries and do not represent accurate relationships to physical features on the map Location:12 TANGLEWOOD DRIVE
such as building locations. Buffer S
Aerial Photos Taken July 10,2009
- - TOWN:OF BARNSTABLE Cam'
LOC qnON or SEWAGE # 2 pO G -
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME &.PHONE NO. L V-_G ry
SEPTIC:TANK CAPACITY; �C�U
LEACHING FACILITY: (type) C'1-�t L✓ SficS� ize).
NO. OF.BEDROOMS
BUILDER OR OWNER act U wS I
PERMITDATE: ' dL�' COMPLIANCE DATE: C � G
Separation Distance Between the:
of Maximum Adjusted Groundwater Table to,the B'ottom of Leaching Facility Feet'`t
Private Water.Supply Well and Leaching Facility. (If any wells exist
f 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 i
Furnished by
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+ Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Ta
fi,nglewood Drive
Property Address
Georgia Cabo 1 a C)s
Owner Owner's Name
information is Osterville Ma. 02655 12/26/2007
required for
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not use the return Name of Inspector
key. Capewide Enterprises,LLC
Company Name
r� P.O.Box 763
Company Address
Centerville Ma. 02632
emm City/Town State Zip Code
(508)428-4028 S 14454
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 ❑ Fads r�
C=
❑ Needs Further Evaluation by the Local Approving Authority "` x
r-)
12/26/2007
Inspec s Signature Date
The system inspector shall submit a copy of this inspection report to the Appr ving ACMorit 9 Board
of Health or DEP)within 30 days of completing this inspection. If the system i a share€i sysUrn or "
has a design flow of 10,000 god or greater, the inspector and the system own r shallfbmi�t e
report to the appropriate regional office of the DEP. The original should be se t 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
p �12
o
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
12 tanglewood dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
W ; Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 12 Tanglewood Drive
Property Address
Georgia Cabo
Owner Owner's Name
information is required for Osterville Ma. 02655 12/26/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be,
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
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:
❑ 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
12 tanglewood dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
I ,
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 12 Tanglewood Drive
Property Address
Georgia Cabo
Owner Owner's Name
information is required for Osterville Ma. 02655 12/26/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
N!D 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):
❑ it, 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.
12 tanglewood dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 12 Tanglewood Drive
Property Address
Georgia Cabo
Owner Owner's Name
information is required for Osterville Ma. 02655 12/26/2007
every 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 -
1-1 ® Liquid depth in cesspool is less than 6 below invert or available volume is less
than Y2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to.clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water'eleyation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
12 tanglewood dr.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Tanglewood Drive
Property Address
Georgia Cabo
Owner Owner's Name
information is required for Osterville Ma. 02655 12/26/2007
every 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-
1 0,000g pd.
❑ ® 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
El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in,accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.'
12 tanglewood dr.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
i
i
i
Commonwealth of Massachusetts
W` Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 12 Tanglewood Drive
Property Address
Georgia Cabo
Owner Owner's Name
information is required for Osterville Ma. 02655 12/26/2007
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
M ❑ Has the system received normal flows in the previous two week period?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ElWere 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.
0 ® 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)]
12 tanglewood dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Tanglewood Drive
Property Address
Georgia Cabo
Owner Owner's Name
information is required for Osterville Ma. 02655 12/26/2007
i
every 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: unknown
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system.inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage (gpd)): 2006:116,000
9 ( Y g 2007:69,000
Sump pump? ❑ Yes ® No
Last date of occupancy: Date 2007
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):
12 tanglewood dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
f
Commonwealth of Massachusetts
W Tit'le 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Tanglewood Drive
Property Address
Georgia Cabo
Owner Owner's Name
information is
requir ed for Osterville Ma. 02655 12/26/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
New SAS installed 2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
12 tanglewood dr.•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official . Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Tanglewood Drive
Property Address
Georgia Cabo -
Owner Owner's Name
information Osterville Ma. 02655 12/26/2007
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) ,
Building Sewer(locate on site plan):
Depth below grade: 5'feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: _ 10+
feet
Comments (on-condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
Depth below grade: 5
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gallon
4"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
28
7"
Scum thickness
611
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or'baffle
12"
How were dimensions determined? Measured
12 tanglewood dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
W . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 12 Tanglewood Drive
Property Address
Georgia Cabo
Owner Owner's Name
information is required for Osterville Ma. 02655 12/26/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every 2-3 years.lnlet and outlet tees ate in place.No evidence of Ieakage.Tank
appears structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
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):
12 Tanglewood dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
12 Tanglewood Drive
Property Address
Georgia Cabo
Owner Owner's Name
information is required for Osterville Ma. 02655 12/26/2007
every 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 copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryovey.No evidence of leakage into or
out of box.
Pump Chamber(locate.on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
12 tanglewood dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
I
Commonwealth of Massachusetts
W. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Tanglewood Drive
Property Address
Georgia Cabo
Owner Owner's Name
information is required for Osterville Ma. 02655 12/26/2007
every 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:
4-Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
i
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failue.No ponding or dampsoil.
12 tanglewood dr.-12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°wM 12 Tanglewood Drive,
Property Address
Georgia Cabo
Owner Owner's Name
information is required for Osteryillle Ma. 02655 12/26/2007
every page. City/Town 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.):
12 tanglewood dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Map Page 1 of 2
Town of Barnstable Geographic Information System
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httn://www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=121056&ma... 12/26/2007
Commonwealth of Massachusetts
W' Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
12 Tanglewood Drive
Property Address
Georgia,Cabo
Owner Owner's Name
information is required for Osterville Ma. 02655 12/26/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of leaching 25'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
As-Built Card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:Gaherty& Miller Model 12/16/94 ground water elevations.USED:USGS Observation well
data.USED:Technical Bulletin 92=000-01 plate#2 annual ranges of ground water elevations.
12 tanglewood dr.•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
1HE Town of Barnstable
�pr�
Regulatory Services
.AMSrAB Thomas F. Geiler, Director
MASS. _ g
1639.
n 3� Public.Health:Division .
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on'the"Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic e
System Inspector who conducted the inspection.
ECOJECH
Environmental
www.eco-tech.us
THIS FORM IS A FACSIMILE OF THE STANDARD SEPTIC INSPECTION FORM ISSUED BY THE MASSACHUSETTS DEPARTMENT
OF ENVIRONMENTAL PROTECTION(revised 6/15/2000)
TITLE 5
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION " - -a.-
Property hAddress: 12 Tan lewood Drive ve
PARC
EL
Osterville LOT
Owner's Naive: Nancy&Donald Pitcher
Owner's Address: P.O Box 329
Cummaquid, MA 02637
Date of Inspection: September 19,2004
Name of Inspector: (Please Print) David D. Coughanowr,R.S.
r is
Company Name: Eco-Tech Environnientil r `�
Mailing Address: 43 Triangle Circle
Sandwich.MA 02563 ry
Telephone Number: (508)364-0894CD
1 _
CERTIFICATION STATEMENT: ,
I certify that I have personally inspected the sewage disposal system at this address and that the information repgfted r—
below is true,accurate and complete as of the time of the inspection. The inspection was performed ba ed on my M
training and experience in the proper function and maintenance of on-site sewage disposal systems. I _ a DEP
approved system inspector pursuant to section 15.340 of Title 5 (310 CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature �° Date: �(fp qt
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority
NOTES AND COMMENTS
Inspector's Note-=> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger
any of the failure'criteria listed below. The septic system has been evaluated according to the conditions observed
on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination.
****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
L
R
L
Page 2 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 12 Tanglewood Drive
Osterville
Owner: Nancy&Donald Pitcher
Date of Inspection: September 19, 2004
INSPECTION SUMMARY: Check A,B,C,D or E/ALWAYS complete all of section D:
A] System Passes:
Yes I have not found any information which indicates that any of the failure criteria described in 310 CMR
5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
COMMENTS:
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,or 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:
Observation of sewage backup or breakout.or high static water level in the distribution box is due to broken or
obstructed pipe(s) or due to a broken,settled or tmeven distribution box. The 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 four times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain
2
Page 3 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 12 Tanglewood Drive
Osterville
Owner: Nancy&Donald Pitcher
Date of Inspection: September 19, 2004
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 and 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
surfacemater 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
**Tlus system passes if the well water analysis, performed by a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form
3) OTHER
3
Page 4 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 12 Tanglewood Drive
Osterville
Owner: Nancy&Donald Pitcher
Date of Inspection: September 19, 2004
D) System Failure Criteria applicable to all systems:
You must indicate either"yes" or"no" to each of the following for all inspections:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15,303.
The basis for this determination is identified below. The Board of Health should be contacted to detennine what
will be necessary to correct the failure.
yes no
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool.
X Liquid'depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high groundwater elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well
X Any portion of a cesspool or privy is within 50 feet of a private water supply well
X 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 by a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form)
No (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 detennine 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
You must indicate either"yes" or"no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well.
If you have answered "yes" to any question in Section E the system is considered a significant threat,or answered
"yes" in section D above the large system has failed. The owner or operator of any large system considered a
significant threat under section E or failed under section D shall upgrade the system in accordance with 310 CMR
` 15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 12 Tanglewood Drive
Osterville
Owner: Nancy&Donald Pitcher
Date of Inspection: September 19,2004
Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following:
Yes No
Y _ Pumping information was provided by the owner,occupant or Board of Health.
N Were any of the system components pumped out in the last two weeks?
Y Has the system received normal flows in the previous two week period?
N Have large volumes of water been introduced to the system recently or as part of this inspection?
Y _ Were as built plans of the system obtained and examined?(If they were not available as N/A)
Y Was the facility or dwelling inspected for signs of sewage back-up?
Y _ Was the site inspected for signs of breakout?
including
Y _ Were all system components,Ong the SAS. located on site?
Y _ Were the septic tank manholes uncovered, opened,and the interior of the septic tank inspected for
the condition of the baffles or tees,material of construction,dimensions, depth of liquid, depth of sludge and depth of
scum.?
Y _ Was the facility owner(and occupants, if different from owner)provided with information on the proper
maintenance of subsurface disposal systems?
For information on the proper maintenance of subsurface disposal systems please go to:
WWW.ECO-TECH.US
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Y Existing information.For example,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)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 12 Tanglewood Drive
Osterville
Owner: Nancy&Donald Pitcher `
Date of Inspection: September 19, 2004
FLOW CONDITIONS
RESIDENTIAL
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 gpd
Number of current residents—3
Does the residence have a garbage grinder(yes or no): no
Is laundry on a separate sewage system(yes or no): no :(If yes, separate inspection required)
Laundry system inspected (yes or no):. n/a
Seasonal use(yes or no): no
Water meter readings, if available(last two year's usage(gpd): 184 gpd
Sump Pump(yes or no): no
Last date of occupancy: current
COMMERCIAL/INDU S TRIAL:
Type of establishment:
Design flow(based on 310 CUR 15.203):: gpd
Basis of design flow(seats/persons/sgft/etc.):
Grease trap present: (yes or no)_
Industrial waste holding tank present: (yes or no):
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings, if available:
Last date of occupancy/use:_
OTHER: (Describe):
GENERAL INFORMATION
PUMPING RECORDS
Source of information: System not pumped in recent past(Owner)
Was system pumped as part of the inspection: (yes or no) No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM:
X 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/Alternate technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe)
APPROXIMATE AGE of all components,date installed(if known)and source of information:
Age: 4+years System installed 9/7/2000 (previous inspection report)
Were sewage odors detected when arriving at the site: (yes or no) no
6
f
Page 7 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Tanglewood Drive
Osterville
Owner: Nancy&Donald Pitcher
Date of Inspection: September 19,2004
BUILDING SEWER_(Locate on site plan)
Depth below grade: 3 ft
Material of construction:—cast iron X 40 PVC_other(explain)
Distance from private water supply well or suction line 20+
Comments: (on condition of joints,venting, evidence of leakage, etc.)
Sewer is vented through roof and appears structurally sound with no evidence of leakage or backup into dwelling_
SEPTIC TANK: Yes (locate on site plan) .
Depth below grade: 36 inches
Material of construction: X concrete_metal_fiberglass polyethylene
_other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(yes or no):_(attach a copy of
certificate)
Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon)
Sludge depth: 8 in
Distance from top of sludge to bottom of outlet tee or baffle: 26 in
Scum thickness: 6 in
Distance from top of scum to top of outlet tee or baffle: 8 in
Distance from bottom of scum to bottom of outlet tee or baffle: 10 in
How dimensions were determined: Probe to top of tank
Comments: (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Pumping recommended at this time and maintenance pumping is recommended every 2 years Liquid level at
outlet invert. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out
GREASE TRAP: none (locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene
other(explain)
Dimensions:
Scum thickness.-
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: _
Date of last pumping:
Comments: (on purnping recommendations, inlet and outlet tee or baffle condition,.structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
.SYSTEM INFORMATION(continued)
Property Address: 12 Tanglewood Drive
Osterville
Owner: Nancy&Donald Pitcher
Date of Inspection: September 19,2004
TIGHT OR HOLDING TANK: none (Tank must be pmnped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal _fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design flow: _gallons/day
Alarm present(yes or no):_
Alarm level: _ Alarm in working order(yes or no):_
Date of last pumping:
Comments:(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: Yes (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: at outlet invert
Comments: note if box is level and distribution to outlets i 1 evidence solids
( o is s equal, ev de ce of so ds carryover,any evidence of
leakage into or out of box, etc.)
D-box appears structurally sound with no evidence of leakage in or out.Effluent level at outlet invert.
Few solids in tank.
PUMP CHAMBER: none (locate on site plan)
Pumps in working order: (yes or no)
Alarms in working order: (yes or no)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Tanglewood Drive
Osterville
Owner: Nancy&Donald Pitcher
Date of Inspection: September 19,2004
SOIL ABSORPTION SYSTEM(SAS): Yes (locate on site plan; excavation not required)
If SAS not located, explain why:
Type:
leaclung pits,number
_leaching chambers,number
X leaching galleries, number 1
_leaching trenches, number, length
_leaching fields,number,dimensions
_overflow cesspool, number
—innovative/alternate system Type/name of Technology
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.)
Soils above leaching gallerappeared unsaturated. No evidence of surface ponding breakout lush vegetation or
other evidence of hydraulic failure was observed. An observation hole dug into leaching gallery stone showed no
effluent contact staining and no level of standing effluent was observed in the top 1 foot of stone
CESSPOOLS: none (cesspool must be pumped at time 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 or no):
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
PRIVY: none (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.):
9
n
Page 1.0 of I I
OFFICIAL.INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Tanglewood Drive
Osterville
Owner: NanCV&Donald Pitcher
Date of Inspection: September 19. 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Provide a sketch of the scNNage disposal system including ties to at least two permanent reference landmarks or
benclunarks.Locale all wells within I00' (Locate where public water supply enters the building)
ROUTE 28
LOCATIONS
A B
W LEACHING
GALLERY 1 31 f t 18 f t
> 2 52 ft 29.5 Ft
CL m3 3 65 ft 48 ft
20 D-BOX
O SEPTIC
TANK
Io
A B
LU EXISTING
—I DWELLING
z # 12
WATER LINE
NOT TO SCALE
t0
Y
f
Page 11 of 11
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 Tanglewood Drive
Osterville
Owner: Nancy&Donald Pitcher
Date of Inspection: September 19,2004
SITE EXAM
Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to ground water: 13 feet
Please indicate(check)all methods used to determine high ground water elevation:
Obtained from system design plans on record-If checked. date of design plan reviewed
Observed Site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of health-explain:
Checked local excavators,installers-attach documentation)
X Accessed USGS database
You must describe how you established the high ground water elevation.
Barnstable GIS department records indicate that property is 13 feet above groundwater table.
11
Hickory Hill Association, Inc
P.O. Box 922
Osterville, MA 02655 August 10, 2005
John Klimm, Town Manager
Town of Barnstable
367 Main Street
Hyannis, MA 02601
Dear John:
On August 8, 2005,at a meeting of our Board of Directors,we agreed that a matter of serious
concern be brought to your attention for appropriate action.
Two Osterville properties: 239 Hickory Hill Circle and 12 Tanglewood Drive, appear to be
occupied by more than one family or numbers of unrelated persons. It has been reported to us
that these single family residences may have more than one kitchen.
As Hickory Hill homeowners,we take pride in our property and work hard to enhance everyone's
property values. Realtors,who service the neighborhood, report that the visual blight of
numerous vehicles reelects poorly on local property values.
Whether or not violations are cited we offer our assistance working with Town officials for the
betterment of all concerned.
Sincerely,
Dorothy McGillen,President
1
cc: Tom Perry,Zoning Enforcement ,
Tom McKeon, Health Services
James Crocker, Town Councilor
Barnstable Assessing Search Results Page 1 of 2
tN
17
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Home: Departments:Assessors Division. Property Assessment Search Results
-917 2 TAN V
Owner:
PITCHER, NANCY L&DONALD J Proper Sketch Legend
Map/Parcel/Parcel Extension
121 /056/
Mailing Address i ij� � Pi 33
PITCHER, NANCY L&DONALD J
P O BOX 329i
CUMMAQUID, MA. 02637-0329 i
2005 Assessed Values:
Appraised Value Assessed Value
Building Value: $ 109,000 $109,000
Extra Features: $9,900 $9,900
Outbuildings: $0 $0
Land Value: $ 144,100 $ 144,100 Interactive Property Map: Ma re uires Ply in:
Totals:$263,000 $263,000 I have visited the maps before
iClt 'if1"l�`
Show Me The Map
April 2001 photos available
Sales History:
Owner: Sale Date Book/Page: Sale Price:
PITCHER, NANCY L&DONALD J 9/30/2002 C166727 $245,000
TOWSLEY, GARY A&NANETTE M 8/15/1987 C111957 $32,500
LEBEL, PAUL T&SUZETTE M 9/15/1982 C89570 $4,000
2005 REAL. ESTATE Tax Information: Tax Rates: (per$1,000 of valuation)
Land Bank Tax $47.73 Town Fire District Rates Other f
$6.05 Barnstable-Residential $2.12 Land B.
Barnstable-Commercial $2.80
C.O.M.M. FD Tax(Residential) $265.63 C.O.M.M.-All Classes $1.01
Cotuit FD-All Classes $1.28
Town Tax(Residential) $ 1,591.15 Hyannis-Residential $1.52
Hyannis-Commercial $2.39
W Barnstable-Residential $1.44
W Barnstable-Commercial $2.10
Total: $ 1,904.51 Due to rounding differences these values may vary
http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing... 8/29/2005
Barnstable Assessing Search Results Page 2 of 2
Land and Building Information
Land Building
Lot Size(Acres) 0.48 Year Built 1988
Appraised Value $144,100 Living Area 960
Assessed Value $ 144,100 Replacement Cost$ 118,460
Depreciation 8
Building Value 109,000
Construction Details
Style Ranch Interior Floors Carpet
Model Residential Interior Walls Drywall
Grade Average Grade Heat Fuel Gas
Stories 1 Story Heat Type Hot Water
Exterior Walls Wood ShingleClapboard AC Type None
Roof Structure Gable/Hip Bedrooms 3 Bedrooms
Roof Cover Asph/F GIs/Cmp Bathrooms 2 Bathrooms
Total Rooms 6 Rooms
Extra Building Features
Code Description Units/SQ ft Appraised Value Assessed Value
BFA Bsmt Fin-Aver 720 $9,900 $9,900
Property Sketch Legend
BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished)
BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished)
CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area (Unfinished)
FAT Attic Area(Finished) GAR Garage UTQ Three Quarters Story(Unfinished)
FCP Carport GRIN Greenhouse UUA Unfinished Utility Attic
FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished)
FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck
FOP Open or Screened in Porch TQS Three Quarters Story(Finished)
http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeS ervices/Finance/Assessing... 8/29/2005
Health Complaints
24-Aug-05
Time: 12:36:00 PM Date: 8/24/2005 Complaint Number: 18392
Referred To: DONNA MIORANDI Taken By: JOAN AGOSTINELLI
Complaint Type: CHAPTER II HOUSING
Article X Detail: ILLEGAL OPERATIONS
Business Name:
Number: 239 Street: Hickory Hill Circle
Village: OSTERVILLE Assessors Map_Parcel:
Complaint Description: Letter sent by Hickory Hill Association -
received 8/24/2005 - Overcrowded and
unrelated adult issue and more than one
kitchen-see letter.
Actions Taken/Results:
Investigation Date: Investigation Time:
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'FBORTOLOTTI-CONSTRUCTION INC. '
f 0 765 WAKEBY ROAD,.MARSTONS MILLS, MA 02648
508-771-9399 508-428-892G FAX: 508428-9399
W -SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
LO PART A
CERTIFICATION
r ,
ro dress:
Date of Inspection: Inspector's Name:
(yKBer's Name and Address: _
fJ O
CERTIFICATION STAT . ENT• j
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection:-The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal yystems. The System: ^
� Passes
Conditionally Pass
Needs F4rth =Local Aproving Authority FailsInspector's Signature Date: ��/9 Ta
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty(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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
A)SYS7DEM PASSES: .:
I have not found anv information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
l .
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair, passes inspection.
Indicate yes, nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If
"not determined",explain why not.
The septic tank is metal;cracked, structurally unsound,shows substantial infiltration or
exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The'Board of Health.
Sewag
e bac kku orbreakou breakout h w g stack titer levelobserved in P gthe distribution
o box is due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
- 1 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' .PARTA
CERTIFICATION(continued)
Broken pipe(s)replaced
Obstruction is removed c� /
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or.obstructed pipe(s). '
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
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 the public health, safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
INGIN.A.MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:': i
The system has a septic tank and soil absorption•system and is-within 100 Feet to a surface
` water supply or too-a surface water supply.
The system has a septic tank and soil absorption system and is with.a Zone I of a public
water supply 1 well.
The system has a septic tank and soil absorption system and is within 50'Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100.Feet but 50
Feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5;ppm. R
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool
Static liquid level in the'distnbution box above outlet invert due to an overloaded or clog-
ged SAS orcesspoot. r: �, .,..,
"r ° <t•,, t�Liquid depth in cesspool'is'less than 6"•below inve'mor available,�blurne;is less'than 1/2
day flow.
Required'pumping more titan 4 times in tlie'last yearNy.O!,&6 to clogged or obstructed
pipe(s). Number of times pumped
-2-
c..tQ;t' .i,, . _...s d, m-
SUBSURFACE SEWAGE llISPUSAL"SYS'1'EM`INSPECTION FORM �-
..PART.A
CERTIFICATION (conlimied)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation. '
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone l of a public well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed i
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen:
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because one or more of the following
conditions exist:
The system is within 460 Feet of'surface druiking`waimsupplyf >:4
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)'bi mapped Zone'll of a publicvater'supply:wellP ,- f;
The owner or operator of any such systein'shall bringthe system--and7facility into Tull-compliance with the
groundwater treaimeni program requirements of 314 CMR 5.00 and 6.00., Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CIIECKLIS'1,
Check if the following have been done:
_Vamping information was requested of the owner,occupant,and Board of Health.
None of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
_ As-built plans have been obtained and examined. Note if they are not available with N/A:
�The facility or.dwelling was inspected for signs of sewage back-up.
_ fhe.system does.not receive non-sanitary or industrial waste flow..
The site was inspected for signs of breakout,.•
CAll.system.components,excluding.the Soil Absorption,,System;have been located on site.
Ahe septic tank manholes were uncovered,opened,and the interior of the.sepdc tank was in-
spected for,conditionofbaQles.or tees,,material of•construction,dimensions,depth of liquid,
V4uepth of sludge,depth of scum..
he size and location of the Soil Absorption System on-the site has been determined based on
existing information or approximated by non-intrusive methods.
_g
, y
i
"y 'INSPECTION FORM
'SUBSURFACE SEWAGE DISPOSAL SYSTEM
PART B
CHECKLIST(continued)
The facility owner(and occupants, if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION,FORM'
PART C
s.;SYSTEM.INFORMATION -.
/k FLOW CONDITIONS
RESIDENTULI v
Design Flow: ? gallons Number of Bedrooms: Number of Current Residents:_
Garbage Grinder: Laundry Connected To System: ( Seasonal Use:/00
Water Meter Readings,if ail able:
Last Date of Occupancy: -
Co. INDUSTRIAL:
). I mil._ _._ r a , .. • ,
Nv Y
Type of Establishment:
Design Flow: sallonstday Grease Trap Present:(yes'or no)
Industrial Waste.Holding .
Tank-Present:- -
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,-If-Available: - Last Date of Occupancy:
OTHER: Describe) Y
Last Date of Occupancy;:
GENERAL INFORMATION
PUMPING RECORDS and source of information: C�
System Pumped as part of inspectior42k if yes;volume pu ped: - aallons
Reason for pumping:
TYPE OF SYSTEM:
_Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool,
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain): 71
APPROXIMATE AGX of all components,date installed(if known)and source of information:
- Sewage odors"detected en arriving at tli site: !7
4
Ill -
,F SUBSURFACE-SE WAGE�yISPOSA.L:SY^S'CEM;II.NSPECTION,FORM.
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:—
th below grade: y
Depth g � Material of Constniction: ✓concrete � rnetal FRP Other
(explain)
Dimisions.:!F.S'X�, 'X S-j Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle: 3y F
Distance from bottom of scum to bottom of outlet tee or baffle: >
Comments: (recommendation for pumping,condition of inlet and outlet tees or battles,depth of liquid
level in relation to outlet invert,structural 'integrity,evidence of eakage, etc. ,6 a, /p
GREASE TRAP:— 10o v
Depth Below Grade: Material of Constnrction: concrete metal FRP` Other
(explain) -- — —' —
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlot'te'es or baffles,depth,of li-
level in relation-to outlet invert;stnuctural-integrit),. evidence of leakage;etc.).--
TIGHT OR HOLDING TANK: d,J(U
l of Construction: concrete metal FRP Other(explain)
Depth Below Grade: Materia
Dimensions: Capacity: gallons Design_Floa: gallons/day
Alarm Level:
Comments: (condition of inlet tee, condition of alarm and float switches, etc.)_.
DISTRIBUTION BOX: f/
Depth of liquid level above outlet invert:
Comments: (note if level and distribution is equal,evidence of solids carr},over, evidence of leakage into
or out of box,etc.)
PUMP CHAMBER:�- (� .�
Pump-tstn`worlung order. .4
Comments.* (note condition of pump chamber;condition Ofjnunps and afipnrtenances,etc)
+ r
r y, t r .r ♦Y
Jl
' SUBSURFACE SEWAGE`DISPOSAI SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTIO14 SYSTEM(SAS): ,
(Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
Type.
Leachingits number:_ Leaching chambers, number:
p g be u ber: Leaching gallenes,number:,
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool, number:
Comm Ants: (note condition of soil,signs of hydraulic failure level of ponding,condition of vegetation
eta / C� �
CESSPOOLS: ),-j
Number and configuration: Depth-lop of liquid to inlet invert:
Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:
Materials of construction: Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection) '
Comments: (note condition of soilk,signs of hydraulic failure, level of pondifig,.condition of vegetation,
etc.)
PRIVY:
Materials,of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)-
-6-
'SUBSURFACE SEWAGE'DISPOSAL SYSTEM'INSPECTION FORM ,,
PART C
SYSTEM INFORMATION (continued) '
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
t
._...._. �..._ ,.- - A'• ! i .d,5T�. e• cy `-. �„ .. _...._, sl rze � ..d , zr ''f"'. ,�.
-
.,
DEPTH TO GROUNDWATER:
Depth to groundwater: Feet
Methcd of Determinatio or Ap roxim :tion 12�i1s� 1`"/"'e G/1J5. x
jd�&Zowk-ltf W,�2 74el-
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No...--Q?...!---....... Fims..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® E HEALTH
Appliration for Biipnial Workii Tomitrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sys �at•
..... ---..................... tioio .4 1 i�4l.�-_--
�!
.�
= �......... ......... ... .........
W ca Ad d-dtr
yl- -------------•----............._._. .
Own 9
Installer Address �p
Type of Building Size Lot... _•:_11.. feet
Dwelling—N.o. of Bedrooms............................................Expansion Attic (y, j Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
a' Other fixtures -------••---------•-------•----- .
W Design Flow........`/0..........................gallons per person peg- day. Total da}ly flow.......31A...........................gallons.
WSeptic Tank—Liquid'capacity_L!` allons Length___ .1___. Width................ Diameter---------------- Depth......0........
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing ta�
Percolation Test Results Performed b ,------------'_-��------------------------•----•-•. Date.....
,.a Test Pit No. 1....../..2..minutes per inch Depth of Test Pit.................... Depth to ground water......Aa''�
Li, Test Pit No. 2................minutes'per inch Depth of Test Pit.................... Depth to ground waterj(i__?T..
W -e - ------ --------------- ----
O Description of Soil C}��................. .lti�)v .....-------------- �v
x ...........-............................... ------ _ n.P- ----------------•-•-----•--------------------------•----•------------------------------------...----------------
U
W
UNature of Repairs or Alterations—Answer when applicable.__................................._....____........................................._.......__.
--------••••-------••••-------•-•--•---•-----•-------------•-•---------------------•.........-•--------------------------------•----••-•------------•--•--------------•------•------••--•-----••--.•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL2 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has(,bee ssue by the board of h alth. (' �
CP
Application Approved BY------ �rS`................•-•--- -----•-------•------------------ -•••-• �
; ...
ate
Application Disapproved for the following reasons_____________________________________________________________.................................................
....•.......................................................................•-•-----.........------..L..---------------------------------•-----•-•---------------------------------------------------•-
Date
Permit No...... •-- . ...... Issued.................•-•---------••-•----•--••----------....
Date
Ali
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ .........OF....... ....... ..... .1� ..........................................
Appliratiou for Diapoaal Works Toutitrurtion Vamit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
....................
.. ... ... . . ......
............t.. . . . .. � ...........
r Lot
.........4�1 e.. ...............
_L-ocatio
...... ..L7 A "Z... . ......... - - -
........' .......; ------------- ........... ..... . ;� .................................................................
o of, Address
. .. .... . - 4. 1. .. . .... .......
Installer Address .
Type of Building Size Lot_/,_� feet
Dwelling No. of Bedrooms.........4.................................Ex ansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons_....__.._.................. Showers Cafeteria
Other fixtures ...........................................................
------------------------------------------------------------------*-----------*------------
Design Flow......./ n/. ...........................gallons per person per day. 'Width_....
Total daily flow-------��-L0...........................gallons.
Septic Tank—Liquid capacityA!�� _�:`'gallons Length. ,.P/----- Width....:!'-_....... Diameter________________ Depth......2........
Disposal Trench—No..................... Width.................... Total Length__....._............ Total leaching area....................sq. ft.
Seepage Pit No______________________ Diameter......._._...._..... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box Dosing tank
Performed by--------- ...............
Percolation Test Results ..................................... ........ Date__.. .......
Test Pit No. ;;_._minutes per inch Depth of Test Pit.................... Depth to ground water---------
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground waters ........
--------------------------------------... ........... . .... ..........*"*'*-------------- ------------"-------------------
0 Description of Soil..........Z/��%Z�)_ .............lelf..7)1,/'if�* ,l
..... .......................................................................... ...................
..............
..............Alj�
------------------------ --------------------------_"----------*---------------------*-----------------------------*-----------------------------------------
........................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable-------------------...........................................................................
......................................................................................................................................................%:.................... ..........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I TIL4 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a C ru'fi to of Compliance has issued by the board of lipealth.
_Signed..... --------- ...................
ILI 1AIZA.4
x
ApplicationApproved By..... ....................... .... ......... ............................................. ....... .77
Date
Application Disapproved for the following reasons:............................................................................. ............................
........................................................................................................................................................................................................
i Date
Permit No...... a' �3------ Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........OF......
..................................
Tuerfifiratp of Ton phana
TIIIS IJS TO CERTIFY, Th ndividu4l $ewage Disposal System constructed or Repaired
the I
by.... ...... ......... .................................
Installer
at......Z;'Z-------U-1.......... ........ .............. .......
en_/.S� ..............
has been installed in accordance with the provisions of T I T LE 5 of The State Sanitary Code as ?�scribed in the
application for Disposal Works Construction Permit 1" ( , �_- r_
..... dated-__...----� ......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUAkANTE9 THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
'RAT E................................................................................ Inspector.....................................................................................
120-05& THE COMMONWEALTH OF MASSACHUSETTS
C BOARD 5)F HEALTH
. ...................OF............................................... I..............................
.............. .......
. ................. FEE.........L..�:�
Disposal Works T-PaInstrurtipit "unfit
Permission,is hereby granted..............................................................................................................................................
to Construct or.Re
pair n Individual Sewage Disposal System
at No......zL_7................
............................................ ..................................
Street
-7
7- 2a, ..... ........
as shown on the application for Disposal Works Construction Permr.it
741-/----3-----
Dated----- ........ ...
................ ......................................................
rr
DATE...10 Board of Health
-7..................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
TOWN OF BARNSTABLE
LOCATION., vim, SEWAGE #
VILLAGE ASSES iOR'S MAP & LOTA/,2/
`aOINSTALLER'S NAME & PHONE NO.'XP, �,/f a
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)`l �� �/��� (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
flBUILDER OR OWNER
DATE PERMIT ISSUED: 6 "'l! " 11'7
DATE COMPLIANCE ISSUED;
VARIANCE GRANTED: Yes No /~
I
yr
SYZ
20 FT. MIN.
TOP Ov FOUND. SOIL TESTFF _
EL. = _ _- _ 10 FT ICI IN. IV. GATE OF SOIL TEST
CONCRETE 4'' WITNESSED BY
SCH. 40 P C PIPE CLEAN SAND ~
COVERS MIN. PITCH 1/8'Y PER FT. PERCOLATION RATE Z-
MIN, INCH
OBSERVATION HOLE I OBSERVATION HOLE 2
CONCRETE 2" LAYER OF ELEV. = �_ ELEV.x
4" CAST IR N PIPE 12 COVERS 1
(OR EOUAL� MIN I 1/8"- 1/2" WASHED
PITCH 1/4 PER FT STONE
MEt��� M
FLOW LINE SA rJ a
-
I EL . 7 lJ I i0 MIN y•.• - AND
—
- ��I 2 EL.= _ 20'
EL -_ — ,� i LEVEL =
EL=
EL. _ ;C� a, ;
DIST EL._ _ I o , N0
r BOX oO v o Z WATER AT EL.= 75 WATER AT EL.= j
3/4"- 1 1/2" •� r o
GALLON WASHED STONE %o° ° ` U. o°00 • DESIGN CALCULATIONS
of
SEPTIC TANK W ° EL 7.i, ,
PRECAST LEACHING NUMBER OF BEDROOMS
BASIN OR EQUIV. GARBAGE DISPOSAL UNIT'14 N C)
6 OIAM. TOTAL ESTIMATED FLOW
SEWAGE DISPOSAL SYSTEM PROFILE ' ( - GAL./BR./DAY x BR.) b GAL. DAY }
NOT TO SCALE
REQUIRED SEPTIC TANK CAPACITY ` Q GAL.
ACTUAL SIZE OF SEPTIC TANK %opy, GAL.
BOTTOM OF TEST HOLE OR USGS PROBABLE WATER TABLE EL.=_ rZ` LEACHING AREA REQUIREMENTS
OBSERVED WATER TABLE ( / / ) EL. SIDEWALL AREA Z. - bAL./S.F
BOTTOM AREA C� GAL./S.F
LEACHING CAPACITY ( BOT TOM+SIDEWALL) `' GAL.
�4r• 'ox ox. ' �� + 4Y, 4x L,
,4LMC) TPq t? . - ROUTE L , LEGEND
RESERVE LEACHING CAPACITY -` � �' GAL
EXISTING SPOT ELEVATION OOxO
EXISTING CONTOUR — -- -
�� • _.
00—
INAL SPOT ELEVATION ---
NOTE
S:
�`-- FINAL CONTOUR 00
��\! I. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.Q.E.
SOIL TEST LOCATION !�
UTILITY POLE --p- TITLE 5 AND THE TOWN OF - /,'. ) e; RULES AND
ti REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE.
TOWN WATER W ===W
2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO
�A t,.,,�'r- + CATCH BASIN
WITHIN 12 OF FINISHEO GRADE.
w + n 1= 3• EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY THE SAME.
a ! \ 4. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE
r 3 , OF WITHSTANDING H- 10 LOADING UNLESS THEY ARE UNDER OR
8 Ac r..w WITHIN 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING
MIN. FRONT SET BACK SHALL BE USED UNDER OR WITHIN 10 FT OF DRIVES OR PARKING.
� MIN. REAR SETBACK I�. _ S. ANY MASONARY UNITS USED TO BRING COVERS TO GRADE
MIN. SIDE SETBACK f 0 ` SHALL BE MORTARED IN PLACE.
6. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH
` N DEEDED OR ZONING REGULATIONS. OWNER /APPLICANT IS TO
AJ f OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY.
�%j! APPROVED : B'OARD OF HEALTH
/ , �, a ` DATE AGENT
ol PROJECT LOCATION,
-.
{ a APPLICANT,
4'
� - LET
I y= L EV Y, EL DREDGE, 8 WAG/VER ASSOC. //VC
ENGINEERS - LANDSCAPE ARCFi,TFCTS
PLANNERS - LAND SURVEYORS
889 WFS7 MAIN cT REFT
CF N-1 E RVILLE, MA 02632
N 111J70rn� I � �. +♦ r 1
LOCATION MAP H SHEET OF
i