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HomeMy WebLinkAbout0027 THIRD AVENUE (OST.) - Health 27 Third Avenue Osterville P ,. A 116 073 l 'r o Commonwealth of Massachusetts v Title 5 Official , lnspection Form _ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 27 Third Ave Property Address tS �>x Kathy Horgan �°` S Owner Owner's Name information is -0 required for every Osterville Ma 02655 6/8/17 , page. City/Town State Zip Code _ Date of Inspection 4J t 3"' 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 sly �aa�l on the computer, use only the tab 1. Inspector: key to move.your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain Q Company Name 8 Johns path Company Address S Yarmouth MA 02664 City/Town State Zip Code 508-364-9587 S113522 Telephone Number License Number B. Certification I certify.that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper.function and maintenance of on site. sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/13/17.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 DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority: ****This report only describes conditions at the time of inspection and under the conditions of.use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Il— Commonwealth of Massachusetts W Title 5 .®fficial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Third Ave Property Address Kathy Horgan Owner Owner's Name information is Osterville Ma 02655 6/8/17 required for 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System contains a 1,500 Gallon septic tank as well as a concrete distribution box and 4 500 Gallon leaching chambers. System is functioning as designed 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ; ,. 27 Third Ave Property Address Kathy Horgan Owner. Owner's Name information is required for every Osterville _Ma 02655 6/8/17 page. City/Town State Zip Code Date of Inspection B. Certification (bout.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Third Ave Property Address Kathy Horgan Owner Owner's Name information is required for every Ostervil.le Ma 02655 6/8/17 page. Cityrrown 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 El 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or pondmg 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 1/day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 27 Third Ave Property Address Kathy Horgan Owner Owner's Name information is Osterville Ma 02655 6/8/17 required for every page. City/Town State Zip Code Date of Inspection B: Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: - ,❑ Any portion of-the SAS, cesspool 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. ❑ N 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 nitrogen sensitive area (Interim Wellhead Protection ❑ Area`—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate ' regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Third Ave Property Address Kathy Horgan Owner Owners Name information is required for every Osterville Ma 02655 6/8/17 page. Cityfrown 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? El ® 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 i 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 27 Third Ave M Property Address Kathy Horgan Owner Owner's Name information is required for every Osterville Ma 02655 6/8/17 page. Cityfrown 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? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readin s, if available last 2 ears usage d 328 GPD 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No i ti Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(9Pa) 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts 1pgaffiMmll Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Third Ave Property Address Kathy Horgan Owner Owners Name information is required for every Osterville Ma 02655 6/8/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information . Pumping Records: Source of information: Pumped in 2015 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•3/13 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 27 Third Ave Property Address _. Kathy.Horgan Owner Owner's Name information is required for every Cisterville Ma 02655 6/8/17 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: 3/18/04 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private watersupply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic ii p c Tank (locate on site plan): Depth below grade: 1.5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If-tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments ., 27 Third Ave Property Address Kathy Horgan Owner Owner's Name information is required for every Osterville Ma 02655 6/8/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 31' Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Third Ave „M t Property Address Kathy Horgan Owner Owner's Name information is required for every Osterville Ma 02655 6/8/17 page. Cityrrown 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 grader 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts r W Title 5 -Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Third Ave Property Address Kathy Horgan Owner Owner's Name information is required for every Osterville Ma 02655 6/8/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Fora, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Third Ave Property Address - Kathy Horgan Owner Owner's Name information is required for every Osterville Ma 02655 6/8/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: t leachingchambers f number: 4 ❑ 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.): No signs of failure 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 (Sins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of W Commonwealth of Massachusetts W Title' 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M 27 ThirdAve - - Property Address Kathy Horgan Owner Owner's Name information is required for every Osterville Ma 02655 6/8/17 page. City/Town; State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I Privy (locate on site plan): Materials of construction: Dimensions Depth of solids t Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 i Commonwealth of-Massachusetts Title Official Inspection Form Subsurface Sewage Disposal_System Form - Not for Voluntary:Assessments 27 Third Ave Property Address Kathy Horgan Owner Owner's Name information is required for every Osterville Ma 02655 6/8/17 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17. Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 27 Third Ave Property Address Kathy Horgan Owner Owner's Name information is required for every Osterville Ma 02655 6/8/17 page. Cityrrown 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: 12+ feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins^3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Assessing As-Built Cards Page 1 of 2 t TOWN OF}BARNSTABLEC LOCATION A e Ko_ SEWAGE N M03"1.29 VILLAGE /i',/� ASSESSOR'S MAP&LOT "0 7_? INSTALLER'S NAME&PHGI fE No. SEPTIC TANK CAPACITY e I LEACHING FACILITY: (type) 1� c�16 (siu) fXc . cha►�b� NO.OF BEDROOMS 41 -'-'BUILDER OR OWNE. 8 PERMITDATE: COMPLIANCE DATE: 3 U Separation Distance Betweeg the: Maximum Adjusted GroundwaterTable to the Bottom of Leaching Facility Feet I Private Water Supply Well and Leaching Facility (If anywells exist 5 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 17 e �'••...:• ram.-.+..•/' �r �n � �� http://www.townofbamstable.us/Assessing/HMd,isplay.asp?mappar=l 16073&seq=1 6/5/2017 Commonwealth of Massachusetts W Title-5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M ,•''� 27 Third Ave Property Address Kathy Horgan Owner Owners Name information is required for every Osterville Ma 02655 6/8/17 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•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 27 Third Avenue Property Address Kathy Horgan Owner Owner's Name information is Osterville MA 02655 06/05/10 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: A. General Information When filling out forms on the p computer,use 1. Inspector: Y only the tab key VVY to move your Michael Kellett cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspection Company Name P.O. Box 896 Company Address East Dennis MA 02641 City/Town State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification 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;=si#e sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15i340=of, Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails: ❑ Needs Further Evaluation by the Local Approving Authority 06/05/10 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the.appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 27 Third Avenue Property Address Kathy Horgan Owner Owner's Name information is required for Osterville MA 02655 06/05/10 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: 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 27 Third Avenue Property Address Kathy Horgan Owner Owner's Name information is required for Osterville MA 02655 06/05/10 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass.unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply: ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Third Avenue Property Address Kathy Horgan Owner Owner's Name information is required for Osterville MA 02655 06/05/10 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 El ® 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 more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped- ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 27 Third Avenue Property Address Kathy Horgan Owner Owner's Name information is Osterville MA 02655 06/05/10 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cunt.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ Z 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. Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 27 Third Avenue Property Address Kathy Horgan Owner Owner's Name information is required for Osterville MA 02655 06/05/10 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? ❑ 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? ® ❑ 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. ® Ei 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)] f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 27 Third Avenue Property Address Kathy Horgan Owner Owner's Name information is Osterville MA 02655 06/05/10 required for every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No current Last date of occupancy: 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? ❑T Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitay waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter,readings, if available: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Third Avenue Property Address Kathy Horgan Owner Owner's Name information is Osterville MA 02655 06/05/10 required for every page. Cityfrown 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: 03/18/04 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No E Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 27 Third Avenue Property Address Kathy Horgan Owner Owner's Name information is required for Osterville MA 02655 06/05/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2.0 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: f. et 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: 1500 gal 4" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 28" 3 Scum thickness 6„ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" measured How were dimensions determined? Commonwealth of Massachusetts Iva W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 27 Third Avenue Property Address Kathy Horgan Owner Owner's Name information is required for Osterville MA 02655 06/05/10 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.): The tank was sound and tight with tees in place and liquid at 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 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): � I i_ Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 27 Third Avenue Property Address Kathy Horgan Owner Owner's Name information is required for Osterville MA 02655 06/05/10 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 even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): . Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 27 Third Avenue Property Address Kathy Horgan Owner Owner's Name information is required for Osterville MA 02655 06/05/10 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 ❑ 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.): This system has four drywells in a12'x 36'field of stone. The stone were dry with no sign of ponding or failure. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Third Avenue Property Address Kathy Horgan Owner Owner's Name information is required for Osterville MA 02655 06/05/10 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.): Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments cw 27 Third Avenue M Property Address Kathy Horgan Owner Owner's Name information is required for Osterville MA 02655 06/05/10 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate whey public water supply enters the building. I a� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 27 Third Avenue Property Address Kathy Horgan Owner Owner's Name information is required for Ostefville MA 02655 06/05/10 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: 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: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe.how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet. TOWN OF BARNSTABLE LOC:XTION ef," e-hV SEWAGE # 3-1I ? ASSESSOR'S MAP & LOT '""C7VII LAGS3; INSTALLER'S NAME&PHONE NO. D/1P! Qom` SEPTIC TANK CAPACrily 44e) LEACHING FACILITY: (type) � i (size) ,�.2 X�y ' 41�Ar+�sr NO.OF BEDROOMS 41 _ BUILDER OR OWNER `- PERMTTDATE: COMPLIANCE DATE: 3 (/ 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 k " � '3 g s Sr7 s. /tee ,�,f) No. c)-©C) � ^ t /g Fee f/ e THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: J/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Zioogal bpotem Construction Permit Application for a Permit to Construct(✓)Repair( )Upgrade( )Abandon( ) C Complete System ❑Individual Components Location Address or Lot No.7_1 T hard A C. Owner's Name,Address and Tel.No. 051kecw,112 MN. OjAer-j.q- K614►nys L-L.C. Assessor's Map/Parcel c/o RobtrIc $re"* 110-073 ?-0. Sah 70clOs r4A\ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 50%.rah En91,0%eer �� 7 PvrKer i'%oac4, '�i.�8o� fo59 Type of Building: Dwelling No.of Bedrooms_�_ Lot Size 10 j 90 sq.ft. Garbage Grinder(,VO) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow %0 Z gallons per day. Calculated daily flow 4q O gallons. Plan Date Number of sheets I Revision Date 4MI05 Title 51TF -PLAIN Size of Septic Tank 1500 &AL. Type of S.A.S. y- 500 �AL CNA►Yl$EQS � XIJ IZ x 3to F'tELD Description of Soil 0-91% A SILZY SAND 9-3Z� B ME1b SAub -S014F VtOCS 3Z'� C MED SI}u� P* 10,50(0 Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been' of H h. Sign X Date Application Approved by _ Date �o 0-e-11O 3 Application Disapproved for the following reasons Permit No. Date Issued G ———————————-- �a ! x` Noy t ):Zd Fee r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBIC HEALTH DIVISION—TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Mgpoar *pgtem Construction Permit Application for a Permit to Construct(v*�Repair( )Upgrade( )Abandon( ) Q"Complete System ❑Individual Components Location Address or Lot No.Z._7 'T'Vi 1rck AVC. Owner's Name,Address and Tel.No. Osiecv%lle MN. Os�erv',11� L.L•C• Assessor'sMap/Parcel C/o Rob-er� Iw-07 3 ?.o. 3ok 701NIL - Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 5�\Gunn ' p PgrY.ec R°o�� �i.o:'6px to59 fv��rGf s er.i Sa -4Z8 33`+`i . Type of Building: Dwelling ' No.of Bedrooms Lot Size 10.90�1' sq.ft. Garbage Grinder(N U) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures - Design Flow Yea Z gallons per day. Calculated daily flow yq D gallons. Plan Date 5/510. Number.of sheets I Revision Date 4E0105 Title 5ITF PLAID Size of Septic Tank 1500 CAC.• Type of S.A.S. `f- 500 SAL CNAn'1j?,ekS =IJ IZ:x 3fo' Ft EC.D Description of Soil 0 4' A S I LT S`/ A tJ D q--5f Z ME%>"SAu - 1OL Nature of Repairs or Alterations(Answer when applicable) y 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-this..Board of HHee lth. Sig r-~".''�'� Dated Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued (Q 2— � THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed Repaired( )Upgraded( ) Abandoned( )by at .Z7 ?herd AJe, Os erViIt--e- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. n dated 1,_,1, 41 Installer Designer _ n ft The issuance of this permit shall not be construed as a guarantee that the sys em wi fulic Aon as d i ned.Date Inspector n/1,1 L _)" No. !�'� 6/i� ------------------------Fee r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwiooaf 6p5tem construction Permit Permission is hereby granted to Construct Repair( )Upgrade( )Abandon( ) System located at ' 7 -Third I\Je. ns\eri'Af- and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the dat of this '�rmlt Date:_. /�" ��/U 3 Approved by TOWN OF BARNSTABLE � LOCATION A fllir� �—'hL! SEWAGE # 0003-1)9- VILLAGE �'�S n'� �� ASSESSOR'S MAP & LOT LC 7. INSTALLER'S NAME&PHONE NO. D SEPTIC TANK CAPACITY 14 And � g1 LEACHING FACILITY: (type) ] (size) , —Z � �i size 2 XI NO.OF BEDROOMS I./ L�t1�D BUILDER OR OWNE PERMITDATE: COMPLIANCE DATE: 311flo 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 >v i t� f Town of Blarnstable P#° )O,50( Department of Health,Safety,and Environmental Services 'THE Tgr_ Public Health Division Date - "Q-3 � o. 367 Main Street,I lyannis MA 02601 BARN9TAHM 1639. �� AlFDAAA<1. Date Scheduled Tta )7 13 . a pp Time Fee Pd. � Soil Suitability Assessment for Sewage Disposal Performed By:S v I I/VA r) t'73 17 i e I X• Witnessed By: ' W V�X 4 LOCATION &,;;GENERAL'INI+OIlIYIATION Location Address I YC Owner's Name QSiec i;\k Hq rIts L s�-er r J"/l �o RobeC'� 3ceg�`� e- Address . 1�A 709 1 o�P�UtL rt•�q. Assessor's Map/Parcel: /Y/Q�O /I w Mad0 73 . Engineer's Name NEW CONSTRUC'PION k REPAIR Telephone H df-t 33 qV Land Use AFS ICeA t e\t %Slopes n o A/A P ( )�'� �O Surface Stones t Distances from: Open Water Body tt Possible Wet Area R Drinking Water Well 1;00 ± Il ' t Drainage Way 5m — It Property Line R Other Nb n SKETCH: (Street name,dimensions.of lot,exact locations of test holes&Pere tests,locate wellands in proximity to holes) U ---- AVENUE Hs73 3� Z THIRD I,tl �TI�Z .2 7 AC' 10 `1_ C t� t1 Parent material(geologic) LJ9 � � (ql f\ Depth to Bedrock Depth to Groundwater: Standing Water in Hole: NA Weeping from Pit Pace A/A Estimated Seasonal Iligh Groundwater FL Z.5 ( R.OK1 I 0 I &RwAll1.WRTtr R� IVA�1 DE'I'Lh1VIINA'TYON 'C�RSI'JAdNAL RIOT WATLR JAT3 ,1J Method Used. N/•�• 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 N ._. Reading Date:._ Index Well level - - Adj.floor Adj.Groundwater Level 777.77 PERCOLATION TEST: nat�t 7 jnre (J F tion �_ rime at 9" Depth of Pere 38 rime at 6" Start Pre-soak'rime a J Z5 6ALWN5 Time(9"-6") End Pre-soak ((( ZN $min Rate Min./Inch Z M� Silc Suitability Assessment: Site Passed ✓ Site failed: Additional Testing Needed(YIN) Original: Public l►ealth Division Observation Bole Data To Be Completed on Back j Copy: Applicant i DEE OBSERVATION IIOI,E LQG Ilol�# r Depth from Soil Ilorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Molding (Structure,Stones,13oulderes. isten� ° 'ravel U-�I`"� � SIFT` SAn1D I� 3 L rneo sgND IMK 5/ O 5P,"b z.sv — DEEP OBSERVATION HOLE LOG I:Iolc# Z Dep(b from Soil Horizon Soil Texture, Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,I3ouldcres. onsi tgncy.%Gravel) I, SICTY SAtll> 10193 m� SAND I-- 3Z 3 So M RN S toy S 5/c� IMED• SW-Q z.Sy c� -12-7�1 me ib. SOD Z.5Y 6A, 7.5 Y k 1 Z7-136 C5 mEt� 500 Z.S 7 .::DEEt'0I3SERVf1T1ON IIOLE LOG tIo�e# Depth from Soil Ilorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Molding (Structure,Stories,[3ouldcres. onsistcnc °°Gravel l)EEI':'OI3SERVATION` IOL LOG Ilolc# Depth from Soil Ilorizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,l3ouldcres. . -- — - Consistencv.%Graven I Flood Insurance Rate Mau• Above 500 year flood boundary No_ Yes 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 material exist in all areas observed throughout the area proposed for the soil absorption system? Xe-s If not, what is the depth of naturally occurring pervious material? Certification I certify that on ARIL 1135 (date) I have passed the soil evaluator examination approved by the De partment of Environmental Protection and that the above analysis was performed by me consistent with the required 'ring,ex -tise nd experience described in 310 CM 15.017. 'Signature O Date { DECK OFFICE \ B DROO HALLWAYL_J _ MASTER EDROOM FUTUR i+ BATH b ❑ LIVING h ROOM ----------L k OPEN BATH l \, CLOSET % SECOND FLOOR AREA: UNDER ROOF-886 SF DECK-215 SF 4. f e 1T-0. ❑ BEDROOM / SCREEN i b PORCH i ❑ � J ITCHE 1 �/ ` BATH DRESSING HALULIBRARY LFARMERS n PORCH II " T- LIVING ROOM j I II § GARAGE ENTRY MUD/ i1 ATH LAUNDRY 24'-0' FIRST FLOOR AREA: UNDER ROOF-2097 SF (INCL.GARAGE) DECK-451 SF GARAGE-508 SF COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM FEIVED PART A CERTIFICATION MAY 2 9 2002 Property Address: 27 Third Avenue TOWN OF BARNSTABLE Osterville, MA 02655 HEALTH DEPT. Owner's Name: Peter Brown G Owner's Address: Same Date of Inspection: May 17, 2002 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Map: 116 Osterville,MA 02655-0049 Parcel: 073 - ,Telephone Number: (508) 862-9400 Lot:25 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15 340 of Title 5(310 CMR 15.000). The system: ✓ Passes Co d ionally Passes Ne ds!Further Evaluation by the Local Approving Authority Fai s I Inspector's Signature: Date: May 20, 2002 The system inspector shall sub 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 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 27 Third Avenue Osterville MA Owner: Peter Brown Date of Inspection: May 17, 2002 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: 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 l Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 27 Third Avenue Osterville, AM Owner: Peter Brown Date of Inspection: May 17, 2002 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. 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: i 3 Page 4 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART A CERTIFICATION (continued) Property Address: 27 Third Avenue Osterville, MA Owner: Peter Brown Date of Inspection: May 17, 2002 D. System Failure Criteria applicable to all systems: You must indicate either`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 '/2 day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 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.] 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 determine what will be necessary to correct the failure. E. Large System: 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 i Page 5 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 27 Third Avenue Osterville, MA Owner: Peter Brown Date of Inspection: May 17, 2002 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: 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)]. 5 l Page 6 of l 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 27 Third Avenue Osterville, AM Owner: Peter Brown Date of Inspection: May 17, 2002 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 _ Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does 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): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2001 -41 000 Qals.; 2000-43,000 Qals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAI✓INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: Never pumped-per 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 ✓ 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: 1994-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Third Avenue Osterville, MA Owner: Peter Brown Date of Inspection: May 17, 2002 BUILDING SEWER(locate on site plan) Depth below grade: Approx. 28" Materials of construction: _cast iron ✓ 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16" 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: 1000 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: Measuring 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.): Tees were present The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping every 3 years 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 pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 1. Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Third Avenue Osterville, AM Owner: Peter Brown Date of Inspection: May 17, 2002 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or.no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was level There were no signs of solids. The cover was approximately 30"below grade. 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: 27 Third Avenue Osterville, MA Owner: Peter Brown Date of Inspection: May 17, 2002 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 gal.) leaching chambers,number: leaching galleries,number: leaching trenches;number, length: leaching fields,.number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): The pit had 3'6"ofwater on the bottom. The scum line was at the same level. There were no signs of failure. The cover was approximately 12"below grade. CESSPOOLS: None (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 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 i Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Third Avenue Osterville, AM Owner: Peter Brown Date of Inspection: May 17, 2002 Map: 116 Parcel: 073 SKETCH OF SEWAGE DISPOSAL SYSTEM Lot:25 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. Al - 9 1 - as Al f3 1 Q V, Ay - 3-2 10 V .' Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 27 Third Avenue Osterville, MA Owner: Peter Brown Date of Inspection: May 17, 2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25' +/- 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: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS'database-explain: You must describe how you established the high ground water elevation: The bottom ofthe leach pit to grade was approximately 9. Using the Barnstable topographic map and the Cape Cod Commission water contours maps the maps were showing approximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 2� TOWN OF BARNSTABLE l_��It', SEWAGE # VF LAC,,E OSTiry, ASSESSOR'S MAP & LOT// 0-7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY f 0,0,0 LEACHING FACILITY: (type) /0V0 OAL (size) &XG NO. OF BEDROOMS CA- BUILDER OR OWNER ?,Aev grOL,//\ 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 within 300 feet of leachin�facility) Feet Furnished by T^S/JtG�lo� J � /� Al Aj &1 1':7 is" a 3 M Ay 3-2 y 13,1 - a-a . L -1 TOWN OF BARNSTABLE _.v_-� LO(:'ATION.oQ•` �' }(..1 SEWAGE VILLAGE I ( ASSESSOR'S MAP & LOT OG-0-73 INSTALLER'S NAME & PHONE NO. Ca l SEPTIC TANK CAPACITY. L , MQ ` LEACHING FACILITY:(type) (sue) IOL1U NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WAT R BUILDER OR OWNERS }: DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED:--3Z1-7 VARIANCE GRANTED: Yes No �---�- -- - - .. .. � ;,: . <� �I � �-� r.�'� ��, � I � � ��'> r } �� r y "�7 . � �;i _--� �. ,/. ii�y � S� Y�, • t: 0 own �E COMMONWEALTH OF MASSACHUSETTS ARD OF HEALTH signer Dato TOWN OF BARNSTABLE Apphratiutt for Di-nVn!3ttl Works Tun,itrurtiun rautit Application is hereby made for a Permit to Construct ( ) or Repair (/,�)"an Individual Sewage Disposal Sysem 7t t R�...1 � • Lo i- ddress or. j -----.. `•L— ----•- -•--•-.....� � i �1 ¢ .._...------•-------------------------------- C ,a Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms________________� --------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ _ _ -------- ----------------------------------------•---------- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length________________ Width---------------- Diameter__....___.___-__ Depth-------------_.. 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 tank ( ) Percolation Test Results Performed by-------- ---------- ...................................................... Date........................................ Test Pit No. I________________minutes per inch Depth of Test Pit-_-___.__.__________ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.................. -------------------------------------------••-----•-••---•-•••••-•----------------------------•••---......................................................... 0 Description of Soil........................................................................................................................................................................ x U --•-•-------•------------------•---------.__---...___----------------•--••--•-•-•-•...----------------••------------------•-----•---•...•--.........--------........................................... W U Natgre of Repairs or Alterations Answer when applicable.____-J-'.).O.�O___clut:... ln)............................. 1r�0-0 : , .. ...._ :-.► _x----------------------------------------------------------•--------..........__.________--.--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b the board h alth. ----- ---------------- _3. ...... Application Approved By .. .. .. . ...._....... .�----- 10-----.-- 4 /J� Application Disapproved for the following r as ns: ............... ............................................... .. -----------------------...............-------------------......------------------------------ ........................................ Permit No. � Issued .................. ice...... ----......—"— Dace k IL No. _ ; _....... F�$........ :........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ,, firatiun for Diu u3 t� urk� C�u$t rnrttun [Trutt Application is hereby made for a Permit to Construct ( ) or Repair (:,t;,?an Individual Sewage Disposal System at: �- r IR>i Addressely�� � or(�°t No. 5.T.C! .I.........�i ....................•---- ........... .............................................. _ Ad r ss W ......._. t�� 1�`�"K'_r�1.� ;.r..'...................r Installer Address Type of Building Size Lot............................Sq. feet U s Dwelling—No. of Bedrooms.............i°_: .__________..--_.---Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building --------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------------------------------------------------------------- w Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. W Septic Tank—Liquid capacity------------gallons Length---------------- Width.-.__---.._----. Diameter---............. Depth................ 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 tank ( ) •" Percolation Test Results Performed by.......................................................................... Date........................................ a 0.4 Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water..................... (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... P+ -------------------------------------------------•--•-----------•-------------...----------...--•--•......................................................... 0 Description of Soil........................................................................................................................................................................ x U .---------------------------------------------------••--------------•---•-----------------•----------•------------------... -•-----------•----------------•------------------------'•-------••---•--••--- 7. U Nature of Repairs or Alterations—Answ.er when applicable._----1.7.)4%106 __: r .+_.__'� .1.)'? .:..`.-:.:!.............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b the board f 7halth . Signed L- Application Approved By /r; . t �.. ..: ..L. y------ ��' ' r` i � ��-,............. ��.1.� ...............` .;... \.i ✓ r' r.. .....�I- Dace Application Disapproved for the following rea�nr: ..... --- ------ -------- ----------------------------------------------------------------------- ------------------------------------- Permit No. -------�---- .................... Issued Due Dace ----------------------------------------- ----------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ger#ifi ate of Tampliance TH.IIS,U TO CERTIFY, What lthe Individual Sewage Disposal System constructed ( ) or Repaired by ...........J.0'5.,Dh „ Insriuer / at -----`f ..'.�. .......`� �� 1:��� j' lJ�t ........r� ----------------------------------------- ----------------------------------------------------- has been installed in accordance with the provisions of TITI.E of he State Environmental Code as described in the application for Disposal Works Construction Permit No. -��L _...------- �. .._.. dated .._._........-.._..._..-----_---------.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE ONSTRUE AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. jJ -- / f)L`1 f M DATE..�`�>l..f.... ..1. ........................................................-._... Inspector --------------------------------- -----------------------.---------------- ------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J TOWN OF BARNSTABLEy No .............!..... FEE...::... ...... I � . . C��n�nu�rn.r#imrn �rrnttt , Permission is hereby granted...-.: �--' I..:'.. 1" � .- _ "_ - '-- .-'-r�f! .f.. .�! C to Construe �j ) or Repair ( f n Individ .1�ewa eCDispo System at No. F.y) `` ` �.L1 t i r � ��.__. _ .!.IL I, -- ----------------- ----------------------------- �� Street as shown on the application for Disposal Works Constructio �Pe mit No /llated-----___-.--/!.-I-----------.------------- r/� Board of�Health DATE. = � �/ 1 ,-.7............................ r 1� FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS -__...........-_.__ __ .._.__ __J ..._--_-.___. .. .... _._- ..-_. _ _ .. ' ?P 71 I � of I i �' .-.—.—_._--J � ��- - I r l -I ��`, '� �l ,1 ' i� ' •I �� t�l V..1� - - _ i rzzz Iv i r+� - Li -}- hi ----------------------- r�I , � - I I �, - ��� - ` �aU LrT�-J(a �-;—�I "I`J,) V2 1'�r �•n� uNc� � � i _ i i LL1. u lL{ LIA C � U rh Y — I L W � OF 7 - �T1 JOH: - 4Ar:N DA i ' I t rx 6�4 Ou Z 1 � I ! I � , i i t _..----- ----.. — _ --� ' � III il: �; � � �•_ 1.. 1 L1 SKY_.Y: t I I I j rrr I � reu —ITT. -_. C7I f i JI; ON ' - LLL...III erxvf WA"N '+i I I LLI I 1F f U Q I Ill I - � S �SHEET 4 0- 7 -_,-ice" t 5GaLH: 114" +- - _ D12.=':LAN u'f: K'ri CATE: 7/!4/03 �_ah+r ..� e 1 •f•� O• : 0 ZONE: ASSESSORS REF.: Map 116, Parcel 73 ue RC - ( '� ,�� Area (min.) 87,120Sr (RPOD) OVERLAY DISTRICT: •• ''f'�� _ / Md, _ Public W°Y) A v / Franto a (min) 20' -Third (35 Width gm in) 100' AP Aquifer Protection District% ( `� 1 Setbacks: As Shown on Plan Entitled e o .; •+• ''�••. ti� D1 pave 157.04 . 1 Front 20' =• "Revised Groundwater Protection "dl'• ' Ede 1\184't 500 E tot Area ( `� Side 10' Overlay Districts" - April, 1993 , and 148o9fsF ..�. , Rear 0 , : .4 ; ' •: '., •. ,t �1. FLOOD ZONE: ,,�., N •• •• ' �.t Q.. Zone C >P+►nd d (�' t Community Panel No. a _ \ _ ---- --- - ! Ut i #250001 0016 D :. ia' 328' )------- - I t July 2. 1992 M . c ---. , ---'' J d: 1 tom" b r, •o ':i r+ �o .• _ - - o� Location Map: c- % O o ,m o '` NOTES - 18 g ; I. Water Supply For This Lot is Municipal Water. 70 \ 4.5 g n 2.Location of Utilities Shown on This Plan Are Approx. At Least 72 Hours Prior to Any Excavation For This F G. 32.6 F.G.32.0 0. 1! Existing 1 Story shad -; d , Project The Contractor Shall Make The Required t Notification to DIG SAFE- 888-344-7233. Wood Framed Dwelling _ -- -��• 1 � t • n n n. #27 , 3.The Contractor is Required to Secure Appropriate s �_ F' - - j n, t Permits From Town Agencies For Construction 30.1 29.0 46' I �+ Defined by This Plan. 150OGallon Top El.30.0 29.9 Septic Tank 29.65 JZ7_-_ a Grade. 29 45 4.5' I r n i ; ' ; 4.Install Risers as Required to Within 12 of Finished p BotEl. 27.0 . �c ` •'15'00 W / 1CD ' yap,: := <> �S'•': m -- ~ S84. 5.All Structures Buried Four Feet(4) or More or �• / Subject toVehiculartobeH-20Loading. Bedding as "' L2S I Per Title 5 FROM G.\AL M^P .Fan 157.0 g / l 6.Septic System to be Installed in Accordance With �O`itOd 4 / N/F l 310 CMR 15.00 Latest Revision And The Town of Madden, Ann A' 1 Barnstable Board of Health Regulations. DELVELOPED PROFILE OF PROPOSED SEPTIC SYSTEM 7 All Piping to be Sch 40 PVC. Not to Scale Existing Conditions . r e DESIGN DATA Scale: 1 = 20 F _ Single Family-4 Bedroom Dred. No Garbage Grinder Daily Flow: 110 ON 4 = 440 gpd i E Filler ' e>M Septic Tank:440 gpd x 200%=880gpd a�+Fabric Compacted FIII - -�" Use a 1500 Galion Septic Tank. 'N l/a=1/z" �w -idiet LEACHING AREA Pea Stone Ono 440 gpd/0.74= 595 s.f.Required ;,, Sidewall:202't36')2= 192 s.f. , Leaching 3/4"-11/2"Double ( + to �-•' BottomArea:12'••x36' =432 s.f. N chamber Washed i Ave n�w 624 s.f.Total Provided. (36 Wide FubCa Way) __---•-- � ,• ...- \ / _ LEACHING CHAMBER DESIGN ( l lz'lo" i `e+ / Third (`� / Al I Pipes to be Schedule 40 PVC. Use 4 Edge Of Pave , 1 57.04 } �� l -500 Gallon Leaching Chambers in a CROSS SECTION OF CHAMBER N84.15 00„E 12'x 36' Washed Stone Field as Shown. c ALE Lot Area 10,809±SF �\ esrar ~` 20.56' Note:Existing septic system To Be 0. i P#10,506 Date: 06/132003 10' Min ` , \ Reanoved Or Abandoned. 2157 t '" W • � _•�_ v ; � � Performed By: Sullivan Engineering Witnessed By: Sam White,T.O.B.-B.O.H. _ CD , TEST HOLE - 1 TEST HOLE - 2 j p ad p 7, i u GRASS GRASS o O w ' 0" A LAYER-10YR 3/4 EL. 32 0" A LAYER-10YR 3/4 EL. 32 ° O `!, ���-- q o ► DARK YELLOWISH BROWN DARK YELLOWISH BROWN o - Min Foundation ! - t$ m , SITLY SAND SITLY SAND , �= " �T„. Q ! ' i 9" B LAYER- 10YR 5/8 EL. 31.25 9" B LAYER-10YR 518 EL. 31.25 g s to secure o a ! proposed ;, - 1 Note: The intent of this drawing i a o YELLOWISH BROWN YELLOWISH BROWN Zoning Board and Board of Health O I �o e, MED. SAND SOME FINES MED. SAND SOME FINES approval only. It is not to be used for TH2 D-Box 0 �• I cl ' 32" C LAYER-2.5Y 6/6 EL. 29.33 32" C1 LAYER-2.5Y 6/6 EL. 29.33 pp O ' construction. The drawingis only valid ! 0 Min ! ) t OLIVE YELLOW OLIVE YELLOW Y V� o setic proposed Proper __�.'__S , MED. SAND MED. SAND with an original stamp and signature. rO"k °eL�` Deck -'- f 1 38" PERC TEST @ 38"-<2 MINAN EL.28.83 84" C2 LAYER-2.5Y 6/6 EL.25 _ S� 100X Reserve _-_ - 1 . i i %) NO GROUNDWATER ENCOUNTERED OLIVE YELLOW OF APPROX.GROUNDWATER @ EL.2.5 MED. SAND 4 PETER� „ i LENSES OF 7.5YR 4/6 fi 10' Min ` _ S84.15 00 W / I 127" C3 LAYER-2.5Y 7/4 EL.21.42 n°`= ��•LLIVAP, Yo f / l PALE YELLOW re,�. :r7 157.04 / / N� 1 MED. SAND 1 / Madden, Ann A. i 130" NO GROUNDWATER ENCOUNTERED EL.21.17 r / APPROX.GROUNDWATER @ EL.2.5 Proposed lmaro vem en is - - 0 Added Perc Test Data 6/20/03 - Scale: 1 r = 20e Revision JIModified Proppsed,touse Footprint Date: 6/06/03 Title: - - PREPARED BY: PREPARED FOR: Notes/Revision: Site Plan Sullivan En ineerin Inc. V �iSlaf 1.) The property line information shown waszr Engineering, p RObert BreaUl t compiled from available record information. Cb At PO Box 659 7 Parker flood P O BOX 70 9 27 Third Avenue Osterville, MA 02655 Osterville MA 02655 2.) The topographic information was obtained 14. (508)428-3344 (508)428-3115 fax (508)420-3994 (508)420-3995 fax Osterville MA 02655 from an on the ground survey performed on Barnstable (Osterviue), MASS. April 8, 2003. 0 Draft: MJD Field: WHK/MDH 20 0 10 20 40 80 3.) The datum used is NGVD '29, a fixed mean �l sea level datum. Date: Scale: Review: PS Comp/Draft: RRL May 5, 2003 As Shown Proj. # 22042 Drawing # c3o8_tgt