Loading...
HomeMy WebLinkAbout0134 TANGLEWOOD DRIVE - Health 134 TANGLEWOOD DR j� OSTERVILLE }� A= 121-062 - f -t t e TOWN OF BARNSTABLE LOCATION S:�" SEWAGE# -7 VILLAGE (::>P7' ASSESSOR'S MAP&PARCEL I � - �, INSTALLERS NAME&PHONE NO. C7>,W ZeW-9,0'4:� `` SEPTIC TANK �XiM7— CAPACITY �-dr oo00.E2X4 LEACHING FACILITY.(type) (size) Je:X-2��.7_ NO.OF BEDROOMS OWNER 14vel4le PERMIT DATE:_�®-a2 5 '-to> COMPLIANCE DATE: Q Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility t/ 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) s / Feet FURNISHED BY G .z .� .1 0 ' ti IVo.� Vv 'V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIppricatiou for �Digozar Q�pe;tem Cougtructiou Permit ` Application for a Permit to Construct O Repair(Upgrade O Abandon O ❑.Complete System LJ Individual Components Location Address or Lot No. ,Dwner's Name,Address;and Tel.No. af3`G���iGLF Assessor's Map/Parcel,/��—O 6cX. Installer's Name,Address,and Tel.No. Designer's L Name,Address and Tel..No. /f� � $ y `t-' �d�J�(V OA Vr Vr � J 3` �f7✓ 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(min.'required) o gpd Design flow provided ZT. d gP Plan Date Number of sheets > Revision Date Title Size of Septic Tank 'i,I°r�/� �a�� Type of S.A.S. 5°�� Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo d of Health. Signed Date Application Approved by Date Application Disapproved by: Date for the following reasons / Permit No. Date Issued 1A a �•fit M`a.3i--,'�. .,�:; ../' Fee U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -.TOWN OF BARNSTABLE, MASSACHUSETTS Yes pplication for �Biopogal *totem ConOtructton Permit Application for a Permit to Construct O Repair(Upgrade(•) Abandon( D.Complete System A ndividual Components Location Address or Lot No.I37 /�A WeeZ6~ Owner's Name,Address;and Tel.No. Assessor's Map/Parcel�� O lj Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No./ >, � Type of Building: 6 Dwelling No.of Bedrooms _3 Lot Size sq.ft.• Garbage Grinder (. ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Qther Fixtures Design Flow(min.required) gpd Design flow provided d gP Plan Date eU —.I Number of sheets > Revision Date IN Title Size of Septic Tank Type of S.A.S. J met JP"JC a Description of Soil Nature of Repairs or Alterations-(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title'5 of the Environmental Code and not to plac l,the system in operation until a Certificate of Compliance has been issued by this Boa d of"Health. { ; Signed 1 Date Application Approved by Date Q Application Disapproved by: Date for the�folfowing reasons k:,e•:<. . ;' 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 (1.11< Upgraded ( ) Abandoned( )by oe Iyj ,G Q 40,o` at -,1.3 o y,o eOZ O,/V has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. g2M 4 dated 7Z— Installer G�`�l 'y/ � Designer bedrooms Approved design flow / ,gpd The issuance of this permit shall not be c fistrue as a uarantee that the system ill ciion as designt 4 Date 12M Inspector a; r v410 v No. Fee THE COMMONWEALTH OF MASSACHUSETTS — PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS r' lwiq ogal Stem Con6truction ermit � p � Permission is hereby granted to Construct ( ) Repair ( e,)" Upgrade ( ) Abandon ( ) System located at / 3 <" ��er e O J'T. dr 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: Con tructio must be completed within three years of the date of this e it. Date Approved by ram- .s ._ Oct 29 07 05: 52p 506-833-21.77 p. 1 Town ofBarnstable' ' � . . RegWatory Services Thomas F.Ge31er,Director �► - • Pablic HeaRh MWen Thomas McKean,Director 200 Main Streett,Hyanuais,MA 02601 Office:_508-8624644 .gym 508= Installer&Dotener Certification Form r Date: 06+' : �91 UD-1 Designer: � InstaHer:-� Address: . 6mr c V;,AoLkxG6A Address: W�A elf On /'�— "O'� -'� `�`� was issued a permit to install a (date) ! (installer} septic system at t `, ` oov US—based can a design drawn by (address) r� v�12 wtw , I.�l dated I?-, IzC)o (designer) �J-certify thatthe septic system referenced above was insta Ued substaa ially accarrb-ng`t � .*e design,which ma include minor raved es such as lateraal=ocatioa of th (�*;tubt n box and/or sepfic tank I cezWlbal the septic system rem above was hmoed with' z.cllange� greater 6 k 4' lateral relocation of tte SAS or any veluca ra,0 9hou-of any c mupone of the.sepWc%ystena)-but its:accordance with.State&I6,cal:Regdtiaticsi7ts_ Plan revision o cert ed as. t`by designer to f0110W. (Installcx s Sigaature} B. l+ruu4SON s is `� _. 4f i1T)►4t Y (D s Signature) ( owear's. Here) PLEASE RETUR�i TO ]RA S'-ABA] LIC NTH PTqs1[a . C � OF COMM,-JANCE WnE N lQ: OTT-I 4 # . DUa.T CARD ARE RECFXV)g1Q -N- M-RAI S D]t-1W M-SIO N INK YOU _ o:Heaub/sentirine--inner C'f hFrsiRnT,Fnrri3 . " _ Town of Barnstable P# _/1 Department of Regulatory Services aeswazn.rs, j Public Health Division , Date 7 A�� • '.� `-200 Main Street,Hyannis MA 02601 Date Scheduled J 0,Time ,. ,Fee Pd. > , Soil Suitability Assessment for Sewage Disposal Performed By.2 � N Witnessed By: 0PA LOCATION& GENERAL INFORMATION f Location Address Owner's Name Address Assessor's Map/Parcel: � 6 Engineer's Name NEW CONSTRUCTION REPAIR. , , y Telephone# Land Use. es 0 Slo % �� P ( ) Surface Stones Distances from: Open Water Body tt Possible Wet Areas Ia 0 ft Drinking Water Wellft e Drainage Way Property line Other > ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) �k-t�l7G�l � ' I � �ju�LL t ,—; — C to `T1 Z __. co M Parent material(geologic) Depth to Bedrock l b d Depth to Groundwater. Standing Water in Hole: 1 Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: Depth to weeping from side of obs.hole: In, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level.—.--- Adj.factor— Adj. roUndwater Level,,,e r PERCOLATION TEST Date ? e Observation Hole# J TSme at 9" Depth of Pert Time at 6" � Stan Pre-soak Time @ �� /� h Time(g ,6 ) - " i End Pre-soak. ��'4_P, w2 .6 Rate MinJInch .a � Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:1SEP'TIGIPE11CFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Grvel Z- zf= 45 l a - Q C ' DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%O ve DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling '(Structure,Stones,Boulders. Cons' en i :i7l _ Flood Insurance Rate Mau: Above 500 year flood boundary No_ Yes S Within 500 year boundary No Yes Within 100 year flood boundary No— Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious a al exist in all'areas observed throughout the area proposed for the soil absorption system? - If not,what is the depth of natural y occurring pervious material? �_b Certification - - ` I certify that on t7 (date)I have passed the soil evaluator examination approved by the Department of Envir mental Protection and that the above analysis was performed b me consistent with the required training,exile ' e a ,ex p ri c described in 310 CMR 15.0�/2 Signat e Date O 7 Q:\SEPTl0PERCFORM.DOC r Town of Barnstable EVE 1p� Regulatory Services BARNSfABLE, Thomas F. Geiler, Director �3. ,�� Public Health Division AtFD��a Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 May 11, 2006 Ms. Nancy Crocker 134 Tanglewood Drive Osterville, MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5- The septic system owned by you located 134 Tanglewood Drive, Osterville, MA,was last inspected on January 9th,2006 by, Robert J. Bortolotti, a certified septic inspector for the State of Massachusetts. The inspection of your septic system showed that your system has "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Standing water 1' above.stone with dirty water at top of leaching pit. You have 2 years from the date of the system failure to bring the system into compliance. If there are any questions about this reminder, please feel free to contact the Barnstable Health Department. BARNSTABL.E HE TH DEPARTMENT Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health .,t -� COMMONWEALTH''OF IVIASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ^. DEPARTMENT OF ENVIRONMENTAL PROTECTION r V TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM . PART A CERTIFICATION Property Address: +��(� �/f �� e.c?.z�l'� . l�P,✓l�/� Owner's'Name: f Owner's Address .I ay Date of Inspection:( r o �C> Name of Inspector- (please print) Company Nam"- Mailing Address7 % , 06&A? 4 e Telephone Number: CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported. below is true, accurate and complete as of the time of.the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site'sewage disposal systems. I am a DEP approved system.inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:• Passes Conditionally Passes Needs Further Evaluation by the local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or. DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent,to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /( k/ ,P Owner Date of Inspection: Inspection Summary: Check A,B,C,D or E./ALWAYS complete all of Section D A. System Passes: I'have noi;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: 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 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: `] ✓Gam(. L,t ' 1C�[�C /Z�s f. Owner:, " 1� d , Date of Inspection« 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. ' a,. ^ _'.:f .-. M ..: •9 Vie._ 1. System will pass unless Board''of Ilea lthdetermin es*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 l 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 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 I I OFFICIAL INSPECTION:FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) %��/ �e, Property Address: M4 Owner: Date of Inspection: , U 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 day flow Required pumping morethan 4 times in the last year NOT due to clogged or obstructed_pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface . water supply. Any portion of a cesspool or.privy is within a Zone I of a public well: _ ✓ Any portion of a cesspool or privy is within 50 feet of a.private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water:quality analysis.[This system passes if the well water analysis, performed at a'DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence,of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15303,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• 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 f - Property Ad_dress:As Y Owner ' Date of Inspection: / . �J7G . Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No t.:/ Pumping.information was provided by the owner,.occupant,or Board of Health 1/•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? _V/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) LZ_ Was the facility or dwelling inspected for signs of sewage back up? y Was the site inspected for signs of break out? V _ 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? 'y The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no Existing information.For'example,a plan at the Board of Health. Determined in the field(if any of the failure criteria`related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] - Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION Property Address: ✓ 4 /,x• t � /12d Owner: , Date of Inspection: FLOWCONDITIONS RESIDENTIAL (s Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15:203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: . / Does residence have a garbage grinder(yes or no): /V0 " ` Is laundry on a separate sewage system(y s or no);ft/ .[if yes separate inspection required) Laundry system inspected(yes/or no): ✓l Seasonal use: (yes or no):/VO Water meter readings, if available(last 2 years usage(gpd)): / q iloo 7— Sump Pump(yes or no):ZOO r 1 7lzuu' " Last date of occupancy: `(?( ' COM MERCI'AL/INDUSTRIAL�� Type of establishment: Design flow(based on 310 CMR 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 cz Source of in Was system pumped as part of the inspection(yes or no): If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPROF 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 ge of all components,date installed(if known)and source of information Were sewage odors.detected when arriving at the site(yes or now 6 E. Page 7 of 1 1 OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /c. i./�^ " �i '�t°2 Owner: '� Date of I spection �i ( (C BUILDING,SEWER(locate on site plan)�� Depth below grade: Materials of construction:_cast iron . 40 PVC other(explain): Distance from private water supply well or suction line: - z Comments(on condition of joints,venting, evidence of leakage, etc.): ; SEPTIC TANK:ZJ(locate on site plan) 1� Depth below grader 1 Material of construction: ,-concrete_metal fiberglass_polyethylene _other(explain) _ if tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: + `' X �.� �C7 Sludge depth-, (,� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: . Distance from top of scum to top of outlet tee.or baffle: A Distance from bottom of scum to botto�m, Af outlet tee or baffle: . How were dimensions determined- , L n ; . :� -A Comments(on pumping recommendations,thlet and outlet tee or baffle condition,structural integrity, liquid levels as related io outlet invert,evidence of leakage,etc.): {� GREASE TRAP/ (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 pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): 7 : 1 r Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR.YOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �Y .� � ✓�� �f Owner: ` Date of Inspection: _ , 0 `-o . TIGHT or HOLDING TANK: 0 (tank.must be pumped at time of utspection)(locate on.site plan) Depth below grade: Material of construction: concrete metal . fiberglass_polyethylene other(explain):. Dimensions:' Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:�if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:a2,V—/ n� Comments(note if box is level and distribution to outlets t1qual, any evidence of solids carryover,any evidence of —leakage into or out of ox,et .); e � , Q PUMP CHAMBER: 'locate on siteplan). 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:414 ` (° U > Owner: Date of Inspection: L SOIL ABSORPTION SYSTEM (SAS): t (locate on site.plan,excavation not required) If SAS not located explain why: Type - leaching pits,number: 1pching chambers,number: ,,leaching galleries, number:. leaching trenches, number, length: leaching fields,number, dimensions: overflow cesspool,number: _innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, eAd ao CESSPOOLSjk&(eesspool must be pumped as part of inspection)(loca M on site lan) 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:/�6(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 Page 10 of 1 I OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. 04 Owner: Date of Inspection: 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. 1. o, Oar - 151,bail on row 10 Page l l of l l OFFICIAL INSPECTION FORM—SNOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART C SYSTEM INFORMATION(continued) ,41 Pro ert 'Address: /` w Owner: Date of Inspection: C70 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet. Please indicate(check)all methods used to determine the high ground water elevation: 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 with.local excavators, installers-(attach documentation) u,/ Accessed USGS database-explain: You must describe how you established the high ground water elevation: - 5, .0 /0 1 Lary ,,/' ✓I'i.✓/a3 11 5 L , Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 412 (� Lot No. Owner. �� '. �'� Address: Contractor: d l dress: Notes: STEP 1 Measure depth-to water table to nearest 1/10 ft. ................ I �ry�6 Date I .� month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well...............................`.... ..'v:.. OB Water-level range zone ............:.:........ STEP 3 Using 9 y report ort "Current Water Resources Conditions" determine current depth to � water level for index well month/year. STEP 4, Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment ...................... "�• L STEP 5 Estimate depth to high water by,subtracting the water level adjustment (STEP 4) from measured depth to water level at site (STEP 1) :.........: C�p 6 Figure 11--.Reproducible computation form; 1 III 5 °r'o- �1, ( LIAR /i 33 l Commonwealth of Massachusetts Title 5 Official Inspection Fo rm orm Subsurface Sewage Disposal System Form -Not for Voluntary Assessment °M s 134 Tanglewood Drive Property Address Nancy Crocker Owner Owner's Name information is required for every Osterville MA 02655 1-29-2013 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, IIA use only the tab 1. Inspector: UC key to move your cursor-do not David B. Mason use the return Name of Inspector key. David B. Mason Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 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: LU a I Passes ❑ Conditionally Passes ❑ Fails c - ElNeeds Further Evaluation by the Local Approving Authority rn C4 to.�, ` January 29, 2013 M InIn e r's Signature Date . E 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. LAO t5ins•11/10 Title 5 Official Inspection rm ubsurtace Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 134 Tanglewood Drive Property Address Nancy Crocker Owner Owner's Name information is required for every Osterville MA 02655 1-29-2013 page. CityrTown 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: This inspection information represents the condition of the system on January 29, 2013 at Noon and only that date and time nor does the inspection guarentee the future operation of the system. 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 134 Tanglewood Drive Property Address Nancy Crocker Owner Owner's.Name information is required for every Osterville MA 02655 1-29-2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). 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: 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 134 Tanglewood Drive Property Address Nancy Crocker Owner Owner's Name information is required for every Osterville MA 02655 1-29-2013 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 ❑ ® 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 'h day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 134 Tanglewood Drive Property Address Nancy Crocker Owner Owner's Name information is required for every Osterville MA 02655 1-29-2013 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: ❑ M Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts 4 u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 134 Tanglewood Drive Property Address Nancy Crocker Owner Owner's Name information is required for every Osterville MA 02655 1-29-2013 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® � Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 134 Tanglewood Drive Property Address Nancy Crocker Owner Owner's Name information is required for every Osterville MA 02655 1-29-2013 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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)): Detail: 2012; 102,000 gallons and 2011; 146,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current 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: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 134 Tanglewood Drive Property Address Nancy Crocker Owner Owner's Name information is required for every Osterville MA 02655 1-29-2013 page. Cityrrown 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: 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 134 Tanglewood Drive Property Address Nancy Crocker Owner Owner's Name information is required for every Osterville MA 02655 1-29-2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: October 29, 2007 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 25°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.): Observable components appear in working condition Septic Tank(locate on site plan): Depth below grade: 1 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 gal. Typical Sludge depth: 4" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 134 Tanglewood Drive Property Address Nancy Crocker Owner Owner's Name information is required for every Osteryille MA 02655 1-29-2013 page. CitylTown 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 38" Scum thickness 2" 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 12" How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Observable components appear adequte for the age of the tank. Effluent level with outlet invert. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M s 134 Tanglewood Drive Property Address Nancy Crocker Owner Owner's Name information is required for every Osterville MA 02655 1-29-2013 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 working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ' ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 134 Tanglewood Drive Property Address Nancy Crocker Owner Owner's Name information is required for every Osterville MA 02655 1-29-2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level with outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No indication of solids carryover. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 5 134 Tanglewood Drive Property Address Nancy Crocker Owner Owner's Name information is required for every Osterville MA 02655 1-29-2013 page. City/Town State Zip Code Date of Inspection D. System information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 w/4' stone ❑ 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.): Steel cover to grade. Units observed are H2O rated. no ponding at time of inspection. Indication of past ponding. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 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 134 Tanglewood Drive Property Address Nancy Crocker Owner Owner's Name information is required for every Osterville MA 02655 1-29-2013 page. Cityrrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 134 Tanglewood Drive Property Address Nancy Crocker Owner Owner's Name information is required for every Osterville MA 02655 1-29-2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Assessing As-Built Cards Page 1 of 1 TOWN OF BARNSTABLE LOCATION rso00 ,p-r. SEWAGE# = VILLAGE OJ'7.` ASSESSOR'S M/AP&PARCEL /.Zl_ o d% INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY 4SNvZn-_dr LEACHING FACILITY: 3t1 4.Z NO.OF BEDROOMS 3 OWNER C c c.FFaP PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility / Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) ✓ Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) , Feet FURNISHED BY A G Cam- 4 38 http://towm.bamstable.ma.us'Assessing/HMdisplay.asp?mappar--121062&seq=1 1/31/2013 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 134 Tanglewood Drive Property Address Nancy Crocker Owner Owner's Name information is required for every Osterville MA 02655 1-29-2013 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: 20 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: Ground water contour map ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: gourndwater contour map and septic designs in the area Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 134 Tanglewood Drive Property Address Nancy Crocker Owner Owners Name information is required for every Osterville MA 02655 1-29-2013 page. Cityrrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 J�•. 1 :r- r <. Town of Barnstable �2 $ Department of Regulatory Services Public Health Division Date 7 ■6yp m$ 200 Main Street,Hyannis MA 02607 _)'d.IP:;:ic:hczi'uled Time—_ Fee II1d-. Soil Szdtah dity Ass'esssm�esat,�®r tS'ewa a Dp posal � . Pcrl�rmed 13y:�. �7�� •• '""! -1, C_.h_5'Q— Witncsscd By: 1 �. LOCATION&GENERAL WFORAIATION i'p6 I-Motion Address 1 �'/✓/,ic��y y . Owner's Name Addmgs .. Assesr.:r's Map/Patxel: /Z Engineer's Name t✓?�G�iL .,/]J_,(!i i . tYUCMON �RryAPAII2 _e Telephone# 3 i /'� Slopes(ryo) �� O Surfaex '�✓ / Stones _ �r Distana-.:fn]rn: Open Water uody rt Possible Wet qre - ft Drinking W®ter Well . Drainage Way R Property line �l ft Other —1t SKETCH--(Strict name,dimensions of lot,exact locations of cast holes&perc tests,locate weiL-inds in proximity to holes) 1 � ���� .. 1 �j�,t��c_c� tt._6C� l Pac+ a eimterial(geologic) I 'A Depth to Sedrock y Dc,. th to i xomidwater. StandingWater in Bole: W eching from PIt Fltee M'ctinuw.ted:;ra-nonnl High Groundwater IDETIERNUNATION FOR SEASONAL HIGH WATER TABLE Method U%,�& _ Depth Observed standing in obs.hole: In. Depth to Boll mottles: Dcpth to weeping from side of obs.hole: in. Groundwater Adjustment__ In In. `J Index Well tt Reeding Date: ft- IndCX Well level Adj_factor Adj. ran water level PERCOLATION TEST Date ? m Ob=-ovation / L !lose 4J / Time at 9" Time at 6" Start ® � � Time(9"-6") Fuel Fle-soak r _ - Rate Arfirx.Rt'ICh Site Svitabil€ty fi ssessment: Site passod Site Failed: Additional Testing Needed(Y/N) Orizinal: Public Health Division Observation Hole Data To Be Completed on Back---------- -- Percolation test is to be conducted within 100'of wetland,you must!first notify the Barnstable Conselrvation Division at least one(1)week prior to beginning. �°LS EY'tiiCC';°F31Ca_f•'012M_DOt^ ' Sep 10 07 01 : 52p - p. 2 4 LOG P.O �SEgVATION HOLE �IoQc# Depth from Soil Horizon Soil Texture Soil Color Soii Other # Surface(in.) (USDA) (Munsell) Mottling (Structure.Stones:}loulderD. i -- DEEP OBSERVATION MOLE LOG Role# _ Depth from Soil Horizon Soil Texture Soil Color Soil Other - Surface(in_) (USDA) (Munsell) Mottling (Structure,Stoney,Bouklers. Consistency. Gravel) DEEP OBSERVATION HOLE SLOG I101e# Depth fmm Soil Horizon Soil Texture Soil Color Soil Other 4 Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,BOuldtJ'S, Consistency.Yk t . YtA---- t i - DEEP OBSERVATION HOLE LOG Depth from Soil Horizon Soil TextureSoil Color Soll other Surface(in.) (USDA) (Munsell) MoullnII (Structure,Stones.Boulder )£y.'16—avel) f �'loocD iatsurnncc.Rate Ma]e: Above 500 year flood boundary No, Ycy Within 500 year boundary No Yes Within 100 year flood boundary No_/Yes Death of Naturally occurring Pervious Material Doe at least four foot of naturally occurring pervt)us at�tia exist in all areas observed throughout the area proposed for the soil absorption system? J If not,what is the depth of natural y occurring per viou m serial? CFr tiftr:ttion L I certify that on c (date)I have passed the soil evaluator examination approved by the Department of Envir mental Protection and that the above analysis waS performe b me consistent with the required training,e c ex ri c described in 310 CMR 15.017. Signatu xile Dam . 07 i Q:\S,l?['�19C1YLr6tCFOttlrf.DOC r 1Z /-ej��2_ No._../ ./ .7 r• . Fr�s....�®. ...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiou for Bi_nVv!3 al 39ork,i Taaaitrur#ijau runfit. Application is hereby made for a Permit to Construct ( ) or Repair (P4; an Individual Sewage Disposal System at.: ..... .........•••-......... ....•••-•••--••••----••••--------- Location•:\ddres or No. /L441J,D° ..� .._"Ali � .ric l�4/Z....._../�Y_...-l�C�w:ov� . �w Owner Address ►W.a - _VS11M....... .....7&!51_. W ��`I ................... Installer Address QU Type of Building Size Lot---fL3......Sq. feet Dwelling,— No. of Bedrooms.........__�---------------------_._.:Expansion Attic ( ) Garbage Grinder IVO aOther-Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 0.' Other fixtures . -------- --- d •----------•--•--•--• W -- Design- Flow 3 ...............gallons per person er day. Total daiI flow.:__._.--__-_ C1___.....__.:........gallons. WSeptic Tank—Liquid capacity/ ...gallons Length--- 5 __ Width................ Diameter--._-.---.----_. Depth......V.t_t x Disposal Trench-No.. ........I.......... Width----7_----_-.---: Total Length.___x• -�_._.._. Total leaching area...:................sq. ft. Seepage Pit No...L� Diameter.................... Depth below inlet........... ....... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------- ------------------------------------------------------------------ Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water....................... (a Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R+ -----------------------------------------------------------------------------------------------------------------------•....----............................ ® Description of Soil.........................-.............................................................-................................................................................. x W ------------------------------------------------------------------------------------------------ ---------------------------------------------------..................... UNature of Repairs or Alterations—Answer when applicable....I?. ,----- ...... N L`T/L.4-r"Z/!.S L.9 .............................. .............................................. Agreement: r� • ��� The undersigned agrees to install the afbredescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance s b en is ue b he board of health. Signed ..............T �0g� . .............. --/..,.................... ApplicationApproved By ----------------- - -- -- ---------- ------------------ - -- ------ ------•:....................................... ------ �L. ------ e Application Disapproved for the following reasons.:. .............--- --------------------------------_----------•------------------------------------------------ ------ ^ Date Permit No. �-�----- -- Issued ------------- .---r ---------------- ,,. .. _ Date 2- NoNo....-•----------__...--- yam_ :�...,.:r��. Fps.............................. M THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE I :. Appliraation for Mopoml lVorkii TAwitrurtion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: ............................ ..............•-•-••••-------••-------•._......•'------ •--•-•-------------- •-----------... --••••----•-•--•-•----...........-----•.•- D Location-Address or Lot No. •---•--• 7.. i ........ v'....••-l�.C.t./E , G �C... Owner Address j............................. W �j�'?J..0 ('_l,r�S/. C�f•�Ci!�1 7�`� �N!`s'1�-��..........................' t�.`_/YI a -- ... Installer Address Type of Building Size Lot.... ......Sq. feet �-, Dwelling—No. of Bedrooms---__---_--.�---_-_--___--____-_-_-_Expansion Attic ( ) Garbage Grinder (—) 1Q0 aOther—Type of Building -------------------------_ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q Other fixtures ......................................................------------- ---------------------------------------------------- ... ... W Design Flow................ ..............gallons per person per day. Total daily flow.............�2q...................gallons. W Septic Tank—Liquid capacity� --.gallons Length---. � `. Width....�....... Diameter................ Depth...... x Disposal Trench—No. --------i.._....... Width----7------------ Total Length----z,�....... Total leaching area....................sq. ft. 3 Seepage Pit No---f X/s'!^ Diameter-------------------- Depth below inlet___ T-7... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------------ ............................................................. Date...--.................................. a Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P ----------------------------------------------------------------•------------------------------•••--......................................................... 0 Description of Soil....................................... x W UNature of Repairs or Alterations—Answer when applicable- 1 A_________ ______CAJ1=_t .�. ! _...._W1 ....�........�:.....t_�S.�.JI -r() N !-N C ...._ :i S% •N -•--- �ll�.)_ if i .............................................. Agreement: The undersigned agrees to install the afbredescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en is ue byith e board of health. Signed �J .c 1 / .. --v l' / 1... Application.Approved BY --------------- ----//_..' ....._.....- 6t' --------------- ------- Application Disapproved for the following reafonf- -----------------------------------.... -' .................. ' ................ ' ................._... f ' .......................... - -�' -...... _.._.:................. ................._.....'' �. . Die - Issued .... 7j... /� ..... Permit No.� ................-----'-'------------------------- �.. ..... Dace 4 THE COMMONWEALTH OF MASSACHUSETTS / 2- BOARD OF HEALTH TOWN OF BARNSTABLE Tiertiftrate of Tompliance THIS IS TO CERTI��hat the Individual Sewage Disposal System constructed ( ) or Repaired ( �). by - ..... - C�/�� ).t EJ.��7 ----G..-..*5 i�/�%Ur�.1 e� losrdler at ----- ----------_----_-_........................ - ..1....... - /f7%16 1. rr l 2 ............' s �' = - -'" has been installed in accordance with the provisions of TITLE 5 of The State Environmental C de as/described in the application for Disposal Works Construction Permit No. -_ ..__.._ dated �p; l._f' ----_-----..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE p"'. - � - ,-�-----....._ -- --- ---- ---'-' Inspect �"..�. .-- - _._........ THE COMMONWEALTH OF MASSACHUSETTS 2 BOARD OF HEALTH TOWN OF BARNSTABLE No. / ••------- a t FEE..........0.......... Diopoaal Workii Tonotrution "amit Permission is hereby granted................�G "- 1-._.....__.���1u!c-!7*--� to Construct ( ) or Repair (�) an Individual Sewage Disposal System at No..... -' °Y--.. C 1..J U(Jl!�---- Z//LI l��--,------�' vt/t t�4.--•--•-••---.... :l t� Street as shown on the application for Disposal Works Construction Permit No---------- ------------- at¢d...... . :..._��_......_. Board of Health DATE............. -•---------------•-------•- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal PP p works construction permit signed by me dated_ -71—L&)55--� concerning the property located at l3/ meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED: DATE: LICENSED SEPTIC SYS M INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. - D N fk N 47 , 4z --- 34' �O ' 4`�4 ' 03&f TAN �n, L- E vVoolp o y�' CAPE COD RUILOINC Richard Davis INSpEC� 1230 Newtown Road Cotuit, MA 02635 508-420-0260 LETTER OF INITIAL LEAD NON-COMPLIANCE DATE Dear Qooa®T . Thi-s_l_e-t_t- r is� to certify that I inspected the property located at rcz-s(Plo®cos tv _,_apartment no. , and relevant common areas, in the city or town of _tl�ePys��.p.._ , for dangerous levels of lead according to 105 CMR 460 .730 (A) through(F) : Procedures For Initial Inspection,Regulations for Lead Poisoning Prevention and Control, and determined that there were VIOLATIONS. The inspection was conducted on Please be advised that Massachusetts law requires that only certain residential surfaces be free of lead paint . (Deleading must be done by a licenced deleader MASS. state law) NOTE: A copy of the report must be on site at the time of re-inspection which is after the deleading process. STRIP ALL WINDOW WELLS OR COVER WITH FLASHING. SEE NOTE FOR FURTHER REQUIREMENTS. DO NOT PRIME OR REPAINT UNTIL THE INSPECTOR HAS SEEN THE BUILDING. NOTE: MASS. GL CHAPTER 111 S.S . 190-199 Requires that : On both the interior and the exterior of_ any dwelling, loose offending paints or putty, regardless of surface or height, must be removed. The surface should then be sanded, reputtied and repainted with a non-leaded material in order to reduce further deterioration. Any chewable surface within (5) five feet of a standing surface must be stripped to the bare wood and repainted with a non- lead paint . FEDERAL LAW 24CFR Part 35 Dated 1 April 87 requires stripping be done to the (5) five foot level and as above. ** As of above date of regulation Sinc rely, it will be the responsibility of the owner to be aware of any future changes in- the law. Richard Davis I 1074 Inspector Licence # Report # L4 f ©31- At the time of inspection children under 6 were living in the house 0 YES WNO 0 INCONCLUSIVE TOWN OF BARNSTABLE LOCATION 1 3 q `/�' 4&0e'P 40 SEWAGE # VILLAGE O 2 fe/ ,///,/e ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. � ��a ` 'SEPTIC TANK CAPACITY LEACHING FACILFFY: (type) GI �17L �`dO� (size) //is 1 6 NO.OF BEDROOMS BUILDER C OWNER PERMIT DATE: 7— COMPLIANCE DATE: Separation Distance Between the: . Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet t Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet R,. Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i3y Fay 4 ' No........t--��--- F�s...Y. ..............._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliratiun -for Bhip vial Works Tomitrurtion j3.erutit Application is hereby made for a Permit to Construct (t/S or Repair ( ) an Individual Sewage Disposal System at: _._..______•---_- ...-.poi. ......... 14_nG? /-.:--} aft_ Locat_on-Address or Lot No. A5._: Ma. ........................................... Owner Address � Installer Address UType of Building Size Lot:...........................Sq. feet �-, Dwelling—No. of Bedrooms-------3................................Expansion Attic (00) Garbage Grinder (tJe) a`q Other—Type of Building - No. of persons.......4................. Showers (2) — Cafeteria (lea) d Other fixture ---------•-•••-•-------------••-------------------------•--------------------- ----------------------------------------- W Design Flow--------------- ____ ____gallons per person per day. Total daily flow___________________________________-_----___gallons. WSeptic Tank—LiquiA pacity. ___gallons Length---------------- Width................ Diameter______..__-____ Depth--------------- x Disposal Trench—No..................... Width--------------- � �ti ._.:_---- �T�ota 4ilng g area-----------------___sq. ft. Seepage Pit No-____I______________ Diameter_:___&__._..___. Yee h below inl"et_ l _ to al ea area--------------.---sq. ft. Z Other Distribution box ( ) Dosing tank ( ) h• /��/" aPercolation Test Results Performed by --•---- tte-------------------------------------- Test Pit No. 1-----------------minutes per inch Depth of Test Pit------------_....... Depth to ground water-----------.-__-__-__--- fs, Test Pit No. 2................nninutes per inch Depth of Test Pit-___________________ Depth to ground water--------------.____--._- tx � _ Description of Soil----------- ! ---- -- � .-_.. ----- --- - --------- - - w ----- :---- e- -.. — - ------••--------------------------------------------------------- x V 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 Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board ofhealth.. �7.j igned t fc .V---- •-�11-------------- - ------- e Application Approved BY------ = _ = --- ....... Application Disapproved for the following reasons:----------•---•---------------------------- ........................................................ ---•••-••----•-----••-•••.--•---•---•----•--•.__.---•------------------------•••••-- ------------------------------------ Date PermitNo......................................................... Issued...................... ................................. Date No........ --.. Fig$.. - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Applirtttinn -f ttr Diopuiittl Workii Tomitrurtion Vrrmft Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: q I --j�N•C�LL W c.c�� -' ._ C S E K 1L1_ �'o� -4 1�1 °�' �� 115.: Location-Address s or Lot No. �1G51a2D-•--..... -------•--••---------------•- �......�t'o......... `edit.... ..................... tV� Owner Address eY................................ ........... C L= A Installer t 1 Address UType of Building Size Lot............................Sq. feet «-� Dwelling—No. of Bedrooms------3...........S'_ _________________Expansion Attic (No) Garbage Grinder (0o) Q Other—Type of Building - No. of ersdi s---________YP g.----------------•---------- P -------------- Showers (Z) — Cafeteria (Cdo) Other fixture '` d ••-------- ---------•----- --------------------------------------------------------------------------------------- ------------------- W :Design Flow.:_ _:- =:f __--gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid c pacit „a �galloris Length---------------- Width................ Diameter Depth--------------- Disposal . x Trench—No. .................... Width._..___.._....__. Total 1 ' area..-.----_-_.-__--_s ft. I�lf��g ,�� Eate � � q Seepage Pit No_____________________ Diameter--•-___________----- e below inlet o al eng area......_.__.______sq. ft. z Other Distribution box ( ') Dosing tank ( ) d�• ,G�.. � '' a Percolation Test Results, Performed-.by-------- -------------- � •.... .......................... --------------------------------------- a Test-Pit•-No. L---------------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 water--------------------- � ..- � r------ -- -)-�-�-------- --•---•----} .! ----------------- - Cam..• D Description of Soil .............. --- --------- '---`--- / '.. r V r -------•---•------- ------------•------- ---- Yr, W ------------ x -----•---•------------------------•---------.----- V Nature of Rel airs or Alterations—Answer when applicable................................................ ___.__...._...__.:_ ._..._._.. ..__..___.___..... -__•_--------•_-_-_-_•----------------------------------------`---------------------------------- -i h-- ; - -- ---------------.._....-- ---------------- . Agreement: The undersigned agrees 'to install the aforedescribed Individual Sewage Disposal System in accordance with the provisiois of Article,XL.of�the State Sanitary Code The undersigned further agrees not to place the system in operation until a C�ertificate of�-Cjmpliance has been issued by the board of health. ,P igned.... J"`�V� •-----•-----------• -� -.4,1 z ------ } � DZle Application Approved BY - "� .- -- . ------. • / D Application Disapproved for the.following reasons: ...------ i ---=----------- ----------------•----................................... -------------------------------------------------------------•-•-------------------......_.............-----------------.................................................................................. Date i EPermit No. = _. ..._ ----- Issued. f a/ Date Q-------------- T THE COMMONWEALTH OF MASSACHUS.ETTS BOARD OF HEALTH ..........................................OF........................................ ............................................ Qrrtif irtttle of Tompl ttnrr THIS I TO CERTIFY, j4at the Indi idaSee Disposal System constructed ( ) or RepairedrLU lee ______ .. � . __ __l..____.___ ____. w has been instal]e'd in adan wi h the provisions of Article XI f The State Sanitary Code ap jlescrij)ed in the application for Disposal Works Construction Permit-'No.--_-_-_.:__.___.__�._ '`._...__ dated........._. 7.L.�_._.._. THE ISSUANCE OF THIS,CERTIFICATE SHALL NOT-,BE CONSTRUE S A RANTEE THAT THE SYSTEM WILL. FUNCTION SATISf4CTORY. ,, , .. DATEL...- �' ...... Inspector------- ---------------- --- - THE COMMONWEALTH OF MASSACHUSETTS- i `k C7ARD&' OF .' EALTH . ...OF................ No.......... ` FEE ................. • Z:: Permission is hereby granted---------- ----- - ;fh,d - - --- - ....._._.. to Construct Repair,( -)-an individual Sew ge Dis sa] S tem • at No. � Rio, ' d r - --------------------------- ---------- -- --•--• '4 of iG.t!�,,u� re �( `� as shown on the application for Disposal.Works Construction Permit o. :_.._.__. ._ _. 4ed............ .. ...?___ _..____.. .... Board of Health, DATE._f --_-------------= ------•--- FORM 1255 HOBBS & WARREN. ?NC..•PUBLISHERS. „ LOCQTION : 5EWQC4E PERMIT 1J0. W T_QLLER S U&PILE ADDRESS BUILDER 5 Q f MF- e, ADDRESS DflkTE PER"lT ISSUED _ — _�Y 7f� D ATE CONIPU W-ACE ISSUED : �,.. � e. 1l 2� � N I ' 4. 4,7 4-11 LOT 2 34- l 1 =25` r�4 TA N L C Vv/ 0 1-,-� 1 i 7-, ASSESSORS MAP : ���� .= tx TEST HOL- E LOGS - ,, PARCEL : a a �� FLOOD ZONE . ��� /� � '� SO I L EVALUATO : WITNESS : Otr'>a l�ftplD1 12/ - �. � ,.r 1) The Installation shall comply with Title V and Town of f Wrnstable Board of a REFERENCE : >�1�11> Coc�eJ" G� /6 7�. , DATE : uc ,yr '1•`1 ?tx`� I D 1�1ri'1 t , �. ��� _ �_ F 1[ealth .Zegulations. a �/ �35 0/-� Jf/.'�� T.� 0 PERCOLAT I`�N ►'.ATE : L Z Py iu,r. Iw-t 2) The installer shall verify the location of utilities, sewer inverts and septic y,,, ia1 �T �1 �!_ components prior to installation and setting; base elev:�!ions. -�--�� TH- I TH-2 3) All gravity septic pipiny,, to be 4 inch Sch 40 PVC at 1/8" per foot. The first s - two feet out ofthe d-box to the leaching shall be level. � , 1' ��LOW�k IV `� 1 4) This plan is not to be utilised for property line detc�urination nor any other v wr.) purpose other than the proposed system installation. °�1 K1 �wtLl YJ Lvvrl� S / � � � �t ,y) 5) All septic components muss meet Title V specifications. („1 ;2 6 Parking shall not be constructed over 111 0 se)tic components. LOCAT 1 ON MAP ��.lT �� ?� ✓" I 7) The property is bounded by property corners and property lines. ,�� / �� F,,� -� 1 > t�, �1V2,6 8) The property owner shall review design considerations to approve of total w �A,„l � 1 design flow and number of'bedrooms to be considered for design. Receipt of 1611 j payment for the plan and installation based on the plan shall be deemed ✓ / �- -� l ,I 4f� approval of the design flow by the owner. 9) The existing leaching or cessl-)ools shall be pumped Wd filled with material ✓ �ti., �� , �� L per Title V abandonment procedures. Those witilir. the proposer? SAS shall be - 1_t?� To . removed along with coat• min• replaced' l > t ;rt .•, � a �tted soil and r �. � wv (�rt�l0 U1►4ti b e} ac��. w,.,� clean washed s�,.tt.� per Title V specs. / 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch Sf_'11 40 PVC with ends groutecl it' SEPT ! C SYSTEM DES I GN applicable. _--�-- � C. f' 0,3 �� \ ( 1 1) if a garbage grinder exists it is to be removed and is tile. responsibility of the 1' k �------"' — � _ •� ---- `` I � � FLQW'..:ST 1 MATE owner to ensure such, . 12)The installer is to take c: ution in excavation around t c line if applicable L , 70 - --- 1ID 1.3 ! �e insta, e shall vc:tf the, loe•atton, uanht and 6.�Vdtiott ofthe sewer hues , ' ,� � I � sEDR00Ms AT GAL/DAY/BEDROOM 35 GAL/DAY )",,l y � !1' ' ' � ) 1 y � �0, ,,.� exiting the dv.,elling prior to the Inst.,01atiott. ' I SQj SEP1" t C TANK '°`� SAL/DAY x 2 DAYS - 6�GAL g C' - USE 100 1 GALLON SEPTIC TANK_(y�X15T1 LA ti= ✓r i Ci'�It..l D . 11Iv T' ►art.. Cvr�) S01 L ACSORPT I ON SYSTEM V _ VJ �hX -' / i , GE. AREA: '�-�C'' " '--.1—a�—;a '� _? �_� i f��'� 5,,'a n / : .r 80TTOM AREA: -} X I ;7 X �1-I ` 2 rJJ I. SEP7 I C SYSTEM SE G bV I ` tir'�5 7b �1 1I� —` J // t. C/l/C-`�l 1�i✓ , �-"- .-....-. —_ bl IVY lL� ✓\A)( -� T .-.-. �� _ N• iC it , .�}r A - „- /' ,k� � \ �_..• � Lar�S x ��' t. .,.a /8- �". 1).71�t��.-� p�.21C. .� Ae1 1 Li"I S.. a `-.,..,,`/'t �►.�..�.! 't.-.r' `o D GAL SEPTIC 1'IWK �!' Lhtfut,�+�, l _ t I�Z �Ov��� V•Iw��1 �1�^l�� �° ell ; O 7 ', �� R /� 3 SITE AND SEWAGE PLAN LOCATION : w I?��'� `!-' 14-1l.ItIr,V�f Co '\,I At r i PREPARED FOR ;a SCALE . I= _ DAV I D B . MASON Z�o DATE: DBC ENV I RONMEN�A► DESIGNS -" EAST SANDWICH . MA w DATE HEALTH AGENT ( 508 ) 833- 2 177 Z '•....+dr+rror rterrrr..nrr... rr,rrr +u� - _ _ _- _- �, _ -__- -___ _ _ _