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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 Tower Hill Rd
Property Address
Deluca
Owner information Owner's Name 1;'
is required for Cisterville MA 02655 8/9/18
every page. -
City/Town State Zip Code Date of InspectibbW
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
Cityrrown State Zip Code
508.272.6433 13010
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
8/9/18
Inspector's Ignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-fPage 1 of 17
Vz
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 116 Tower Hill Rd
Property Address
Deluca
Owner information Owner's Name
is required for every page. Osterville MA 02655 8/9/18
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.
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
I '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Tower Hill Rd
Property Address
Deluca
Owner information Owner's Name
is required for every page. Osterville MA 02655 8/9/18
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ 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):
brokenpipe(s)are re laced Y ND❑ e p ❑ ❑ N ❑ (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.doc-rev.6/16 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
116 Tower Hill Rd
Property Address
Deluca
Owner information Owner's Name
is required for every page. Osterville MA 02655 8/9/18
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
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
t5ins.doc-rev.6/16 Title 5 Official Inspection Forth: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 , 116 Tower Hill Rd
Property Address
Deluca
Owner information Owner's Name
is required for every page. Osterville MA 02655 8/9/18
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
f -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 116 Tower Hill Rd
Property Address
Deluca
Owner information
Owner's Name
is required for every page. Osterville MA 02655 8/9/18
City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced.to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of breakout?
® ❑ 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): 4,
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins.doc-rev.6116 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
116 Tower Hill Rd
Property Address
Deluca
Owner information Owner's Name
is required for every page. Osterville MA 02655 8/9/18
Cityrrown 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 ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ' 116 Tower Hill Rd
Property Address
Deluca
Owner information Owner's Name
is required for every page. Osterville MA 02655 8/9/18
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 2017 per owner
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 Tower Hill Rd
Property Address
Deluca
Owner information Owner's Name
is required for every page. Osterville MA 02655 8/9/18
City/Town State Zip Code Date of Inspection
D. System Information (cost.)
Approximate age of all components, date installed (if known)and source of information:
Originaseptic tank and new D-box and infiltrators 2010 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2'
Depth below grade: 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.):
Septic Tank(locate on site plan):
Depth below grade: 20"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank appears to be structurally sound, inlet cover raised to 12"
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000g
Sludge depth: 311
t5ins.doc-rev.6116 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
116 Tower Hill Rd
Property Address
Deluca
Owner information Owner's Name
is required for every page. Osterville MA 02655 8/9/18
Citylrown 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 >12
11
Scum thickness trace-1/2"
Distance from top of scum to top of outlet tee or baffle >219
Distance from bottom of scum to bottom of outlet tee or baffle >2"
How were dimensions determined? measured
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.doc•rev.6/16 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 '~ 116 Tower Hill Rd
Property Address
Deluca
Owner information Owner's Name
is required for every page. Osterville MA 02655 8/9/18
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 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.doc•rev.6116 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
116 Tower Hill Rd
Property Address
Deluca
Owner information Owner's Name
is required for every page. Cisterville MA 02655 8/9/18
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
0„
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
H-20 D-box 30" below grade, no adverse conditions
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 112 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 Tower Hill Rd
Property Address
Deluca
Owner information Owner's Name
is required for every page. Osterville MA 02655 8/9/18
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number:
16 infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
El 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.):
16 infiltrators per BOH record, infiltrators were video inspected and are damp at this time, no
indication of past hydraulic 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
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 116 Tower Hill Rd
Property Address
Deluca
Owner information Owner's Name
is required for every page. Osterville MA 02655 8/9/18
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.):
Soils are compact and dry
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.):
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
II
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
' M 't o 116 Tower Hill Rd
Property Address
Deluca
Owner information Owner's Name
is required for every page. Osterville MA 02655 8/9/18
CityrFown 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
n a-
7ED
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 Tower Hill Rd
Property Address
Deluca
Owner information Owner's Name
is required for Osterville MA 02655 8/9/18
every page.a e.
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: >132"
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: 2010 NGW 132"
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health-explain:
4' seperation per 2010 compliance
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping site is 50'msl and nearby surface water is 10' msl
You must describe how you established the high ground water elevation:
See above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 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
M , 116 Tower Hill Rd
Property Address
Deluca
Owner information Owner's Name
is required for every page. Osterville MA 02655 8/9/18
Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
NOV/09/2010/TUE 10:28 AM SandwichTownOffices FAX No• 1 508 833 0018 P, 001/001
Town of Barnstable' '
Regulatory Services
Thomas).Geiler,Director
Y '
a4 . Public.fleaIth Division
a:h Thomas McKean,Director
200 ME&Street,Hyannis,MA 02601
Ofce_-508-862-4644 -Fax: 508-790-6304
installer&Ndoer Ce cation Form
Date:
Designer: U> Cam. installer: geo 4 4- S` :S'
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Address: . `
Address: 9,1 Sr PA,4e K CoAel
C>S± (✓ l!Py�7�s j—
oa,�14o,
�, -
was issued a pe=it to install a
( te) (installer)
septic system at 11(olbAxt Ru QP' based on a design drawn Ly
(address) '
• dated
(deli goer)
!. 1 cexfy that-the septic system refermc.ed above was installed su bstautraXl acct�rd�,�1g'to
. e design, which may include minor approved-changes such as life ,xelocatiort Of the
dvwi utiou box and/or septic tnk ..
A.
I cer.Wthat the septic systean referenced alcove was ins*_Wl pd wi$`'Wa3 z.Changes
gm-ater tfia410' lateral zelocaf�tb -of the SAS or,any veTtical'rabglition-of y compaxx t
of tlae.septic steaa)but is acc ordance with State&7_.ocal eogdlstions. Plan revidgA or
ca�Mified as-bitytissiertd follow, x
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(�St ors zgoature) .r 'MASON m
NO 1066 ,
(I3 er s Si gb attire) f A£ ;9$taap Here).
PLA A.SE REICURN TO E Off• CT . MC xE
. E - =:N 1 SSUEW � : 4� � � F
._
RE t ADM -'TIN:D Z;E F WIC
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Q:Heelth/SeptzclX7esigner ceracatiop orrt
' t _ '
TOWN OF BARNSTABLE
LOCATION )(& j(ewer }di tf 12o W c_k - SEWAGE#,Io/d
VILLAGE ds rC v v t l 1 e ASSESSOR'S MAP&PARCEL
r INSTALLER'S NAME&PHONE NO. Ye.44 S. S h i e f d S s a S' 73 7" O'I G a
SEPTIC TANK CAPACITY /oo D
i
LEACHING FACILITY:(type) (h (,`CS }o'¢- l G� (size) /31,� X A 6
NO.OF BEDROOMS
OWNER,To krs F S f,#'.A f. c>'
PERMIT DATE: 41 - '-/ — /U COMPLIANCE DATE: I 0
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 leac ing facility) Feet
FURNISHED BY �e { S• �,F a]
- as
16
'YA
venr
s' i3
,4
II
No. Fee /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: y
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZIPPYicatiou for Mioonl *pgtem Comaructiou Permit
Application for a Permit to Construct( ) Repair( � Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or I-ot No. , Owner's Name,Address,and Tel.No.
/1 fw �Ow�lr Ni It 9ooel QS�e di //r NA o tt s"S _ c
Assessor's Map/Parcel I t/t . jai t, J fA U h C C-
-7
i3c�a.G Q,9�1c l l�cb
Installer's Name,Address,and Tel.No. Q 5 r ADesigner's Name,Address and Tel.No.
oZ Cse-- YAa Vee I: Au1) 5,.(L),e
Type of Building: 0?&2—
Dwelling No. of Bedrooms 3 Lot SizgU Z C, Z sq. ft. Garbage Grinder ( )
Other Type of Building j7/Vt16 k No.of Persons Showers( ) Cafeteria( )
Other Fixtures 2
Design Flow(min.required) 33 gpd Design flow provided 7`{C( gpd
Plan Date /�a U 3 , 2 G f 6 Number of sheets Revision Date
Title
Size of Septic Tank 1600 C 41 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) )
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by;t"r(oardof Health.
Signed Date /(,/,p
Application Approved by Date
Application Disapproved by: Date
for the following reasons
Permit No. �LOC6 — Date Issued
l
r � •
No. A F Fee
- THE COMMONWEALTH�-' OF MASSACHUSETTS Entered in computer:;
PUBLIC HEALTH DIVISION - TOWN_ OF BARNSTABLE, MASSACHUSETTS
prication for Mi�pdgal *p5teni Construction Permit--
Application jor;a Permit to Construct( ) Repair( Upgrade`O Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No.J(G %O Owner's Name,Address,and Tel.No.
Wfd Hill( 'Ge,4* '(>S'l�/di'//� Yl n oLG fS _ r ,
Assessor's Map/Parcel t v I - 'tfs 10� t^ �7 S (A U
Installer's Name,Address,and Tel.No. 7a t3t a 6 0.4-kC L 1Q cb
Designer's Name,Address and Tel.No. ;
GSA✓✓� !( P s-,A
- �r 1 f• ( (� S o'a
C Ctd- y�h f�� L ✓►+�I� S�,l v{Y < �, 1 C
Type of Building: 3
Dwelling No.of Bedrooms Lot Sizc2_U 7 Z C, Z sq. ft. Garbage Grinder ( )
Other Type of Building /?/1 No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required), 33 gpd Design flow provided 7 y Ct gpd
Plan Date ./A) U 3 2 G G �k Number of sheets 2 Revision Date
Title'
Size of Septic Tank 1600 C /11 Type of S.A.S.
Description of Soil
401*
-
Nature of Repairs or Alterations(Answer when applicable) 4 C rii r tt �`>n ) 4 j i fr
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 thi,,Moard of Health.
Signed tuz;( �In w. Date X/0 v
r
Application Approved by r, S Date I , 20/
Application Disapproved by.— he Date
for.the following reasons
Permit No. 2-o(6 ` I(q Date Issued 1 — a-10
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 �p has been constructed i accordance
with the prov' ions of Title 5 and the for Disposal System Construction Permit No. 900— V 1- dated r`L(—_20fD
Installer. �-�t,. /J .d e,44- _5A.11 A)esigner 2
#bedrooms Approved design floc � 7 y gpd
The issuance of tVit shall not be construed as a guarantee that the system 1 u ction as desi�ned,
t
-Date . - Inspector ---------------
-:
' No. �C��o '-1 - --- --- +---- ----- ------------ Fee. .�" l.✓
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lwigogal 6p!5tem Con.5truction Vermit
Permission is hereby granted to Construct ( ) Repair� n) Upgrade ( ) Ab �don
( )
System located at [
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this pe rnft.
II lr,J
Date I � " q "' 1 Approved by
r.
r.
s. .
Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
116 Tower HIII Road Osterville
Property Address
John and Mary Savage
owner Owner's Name
information is Osteryiile
required for MA 02655 October 4, 2010
every 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: A. General Information When filling out
forms the
computeto r,use 1, Inspector:
only the tab key
to move your David B. Mason
cursor-do not Name of Inspector
use the return '
key. David B. Mason
Company Name
+� 4 Glacier path
Company Address
East Sandwich MA 02537
Cityrrown State Zip Code
508-833-2177 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 DPP approved system Inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000),The system:
® Passes ❑ Conditionally Passes ❑ Fails o
❑ Needs Further Evaluation by the Local Approving Authority e� z
``i o
-n
t
October 5 2010 rn X 1
a Inspector's Si ure Date
The system inspector shall submit a copy of this inspection report to the Approving Auth at {B t r rd
of Health or DEP)within 30 days of completing this inspection. If the system is a shared Mte4
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall subpart th6r-
report to the appropriate regional office of the DEP.The original should be sent to the systeAh oriner
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.
t51na•OB/08 17tle 5 Of(Idal UIBpeCGOA FOfrtt:SUG8UA8Ca SBWB9a D1aD069!'! l8M•Fla 1 Idl 7
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 Tower Hill Road Osterville
Property Address
John and Mary Savage
Owner Owners Name
information is Osterville MA 02655 October 4,2010
required for
every page. Cltyfrown State ZJp Code Date of Inspection
B. Certification (cons.)
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:
Existing 1000 gallon Septic Tank and 1000 gallon leach pit. System passes based on observations
on October 4, 2010 at 12:30 PM. Leaching system is nearing failure, but there is 1 foot of effective
leaching area remaining. Increase in occupancy may result in hydraulic failure of the system. This
inspection is no guarantee that the system will continue to operate correctly from the point of
inspection forward.
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):
t5ns•no Me 5 alricial Inspedon Form.Subsurface Sewage oisposg system•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 Tower Hill Road, Osterville
Property Address
John and Mary Savage
Ovmer Owner's Name
required for
Is Osterville MA 02655 October 4 2010
required for ,
Wary page. Cityrrown state Zip Code Oate of Inspection
B. Certification (cunt.)
B) System Conditionally Passes(cunt.):
❑ 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 faillhg to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMP.
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
�g.091D8 Title 5 Official inapemon Form:subsurface savage Disposal System•Pepe 3 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
110 Tower Hill Road, 4sterville
Property Address
John and Mary Savage
Owner Owner's Name
Information is required for Ostervilfe MA 02655 October 4,2010
every page. City/Town state Zip Code Date of Inspection
B. Certification (cunt.)
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 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 1/2 day flow
t5ins•09= 7fae a Oftldal Inepeaon Form:Subsurface swage olapoeal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 Tower Hill Road, Osterville
Property Address
John and Mary Savage
Owner Owner's game
information is Osterville MA 02655 October 4 2010
reqaired r City/rown Stata Ztp Code Date of Inspection
�Y page.
B. Certification (cunt.)
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.
❑ ® 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 analysts,performed at a DEP certified
laboratory,for fecal colifonn 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 falls. 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
Q ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection
Area—IWFA)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 signfcant 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.
Gins•09108 71%6 Of6del hapedlon Form:Subsurfew Sewage Disposal System•Pape 5 of I7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 Tower Hill Road, Osteryille
Property Address
John and Mary Savage
Owner Owners Name
Information is Ostervi[le MA 02655 October 4,2010
required for
every page. Cityfrown State 71p Coda 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
0 ❑ 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 this
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 NIA)
® ❑ 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
Ming•09/08 71C8 5 Oftel Ins edon Force:Subsurface Sews Dia I Lam�Page 6 of 17
P 9e P�� A
i
Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 Tower Hill Road, Osterville
Property Address
John and Mary Savage
Owner Owner's Name
information is Osterville MA 02655 October 4, 2010
required for
every page. Cllyrrown State dip Code Date of Inspection
D. System Information
Description:
System passes based on the information observed on October 4, 2010 at 12:30PM.This does not
guarentee the continued operation of the system. Increase in occupancy may result in hydraulic
failure.
Number of current residents: 1
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)): yes
Detail:
2008-53,000 gallons and 2009 53,000 gallons Per Osterville Water Dept.called on October 5,2010
Sump pump? ❑ Yes ® No
Last date of occupancy: currentDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(9pd)
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:
t61ns-OM 75b 5 04fes1 it spedon P m:Subzwface Same Dspossl System-Page 7 of 11
I "
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
118 Tower Hill Road, Osterville
Property Address
John and Mary Savage
Owner Owner's Name
information is required for Osterville MA 02655 October 4. 2010
every 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: Not Available
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
' ❑ Ovemow 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):
t5ns•09= Title s Omew mspeeuen;:o":subsurface sewage Disposal System•Page 8 of 17
a
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 Tower Hill Road. Osterville
Property Address
John.and Mary Savage
OwnerInform Owner's Name
required for aft is Osterville MA 02655 October 4, 2010
required
every 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:
June 29, 1994
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Not Applicable
feet
Comments(on condition of joints,venting,evidence of leakage, etc.):
Appears in working order
Septic Tank(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
1000 oallon tank
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:
SAS•MOB Title 5 onioat mePWUOA Form:SUbaJ(faCa Sewage Diapoael System•Page 8 of 17
i
I
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 Tower Hill Road, Osterville
Property Address
John and Mary Savage
O' er Owner's Name
information is required for Osterville MA 02655 October 4,2010
. .
every page. City/Town State Zip Code Data of Inspection
D. System Information (cunt.)
Septic Tank(coat.)
Distance from top of sludge to bottom of outlet tee or baffle 30"approx.
Scum thickness 3
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 1
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.):
Tank appeared in satifactory condition.
Grease Trap(locate on site plan):
Depth below grade: feat
Material of construction:
❑concrete metal U 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
Sins,09W 7199 6 Official Inspection Form:Subsurface Sewage Oleposal Swtem-Page 10 of 17
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 Tower Hill Road, Osterville
Property Address
John and Mary Savage
Owner Owners Name
information
�i,ed torus Osterville MA 02655 October 4. 2010
every page.a e. Cityrrowrt 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 Q 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
wim•colas Tide 6 Offldal Inspecdon Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 Tower Hill Road,Osterville
Property Address
John and Mary Savage
Owner Owner's Name
information is Osterville MA 02655 October 4, 2010
required for
every page. citylrown state Zip Code Pate of Inspection
D. System Information (coat.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert Level with outlet inverts
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 evidence of solids carryover_
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order. El 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:
SAS located and inspected See notes on next page
t9ns 09ro8 Me 5 Official inspadon Form:suteurfece sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 Tower Hill Road Osterville
Property Address
John and Mary Savage
Owner Owner's Name
information is Osterville MA 02655 October 4, 2010
required for
every page. Cityrrown state Zip Code Date of Inspection
D. System Information (cons.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number,length:
❑ leaching fields number,dimensions:
Eloverflow 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.):
1000 gallon leach pit with approx.2 feet of stone as was typical installation for pit. No damp soil or
excessive vegetation.The 6 foot pit had approx.5 feet of standing effluent, leaving approx. 1 foot of
effective leaching area remaining in pit.
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
t6tna•008 Tide 5 Offitaat Inspection Fprm:Su6sv�ac�Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 Tower Hill Road,Ostervi Ile
Property Address
John and Mary Savage
Owner Owners Name
Information is Osterville MA 02655 October 4,2010
required for
every page. city/Town state Zip Code Date of inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
09108 Too s ofodat Inspeeoon FormAubaurfaoe Sewage O*Wat system•Page 14 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
116 Tower Hill Road Osterville
Property Address -
John and Mary Savage
owner Owner's Name
information is
requlmd for Ostervilie MA 02655 October 4,2010
every page. Ci)dTown state Zip Code Date of Inspectton
D. System Information (cons.)
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
tins-08108 -nW 5 of clW fnspKUon Form:SUbeurfeoe-%wage Disposal System•Page 15 of 17
a
I
e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
116 Tower Hill Road, Osterville
Property Address
John and Mary Savage
Owner Owner's Name
information is required for Osterville MA 02655 October 4,2010
every page. Cfty/Town state zip Code Date of Inspection
D. System Information (cons.)
Site Exam:
® Check Slope
® Surface water
Check cellar
❑ Shallow wells
30
Estimated depth to high ground water: 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:
Engineered plan on file
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
S
You must describe how you established the high ground water elevation:
based on pond elevations in area and Town of Barnstable Groundwater Contour Maps.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5me•08I08 TMe 5 Official Inspection Form:svbsurfaee Sewage Olspoaal System•Page 10 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Dlsposal System Form-Not for Voluntary Assessments
116 Tower Hill Road Osterville
Property Address
John and Mary Savage
der Owner's Name
information is required for Osterville MA 02656 October 4,2010
every page. 01tyfrawn State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D,or E checked
j� 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
f5 na•09ro8 Title s off dal Inapsaon Form:Subsurface Sewage Dlsposal System-Page 17 of 17
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Tower hill Rd.
Property Address
Mary Jane &John Savage
Owner . Owner's Name
information is required for Osterville Ma. 02655 9/30/2010
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. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms on the
computer,use 1. Inspector: I
only the tab key
to move your Robert paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
f� P.O.Box 763
Company Address
Centerville Ma. 02632
BRA" City/Town State Zip Code
(508)428-4028 S14454
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 inspecti2e. Thginspection
was performed based on my training and experience in the proper function and maintel4�tce�on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Sect 152,240 of
Title 5 (310 CMR 15.000).The system: --i
❑ Passes rn
❑ Conditionally Passes ® Fails A. ,
❑ Needs Further Evaluation by the Local Approving Authority 3
N W
m
9/30/2010
Insp tor's Signa ure Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal tern•Page df 1
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41M , 116-Tower hill Rd.
Property Address
Mary Jane &John Savage
Owner Owner's Name
information is required for Osterville Ma. 02655 9/30/2010
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.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
/ f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Tower hill Rd.
Property Address
Mary Jane&John Savage
Owner Owner's Name
information is Osterville Ma. 02655 9/30/2010
required for
every 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 FIND (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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 116 Tower hill Rd.
Property Address
Mary Jane&John Savage
Owner Owner's Name
information is required for Osterville Ma. 02655 9/30/2010
every 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
Y 9 p
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 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
ElBackup 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
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Tower hill Rd.
Property Address
Mary Jane &John Savage
Owner Owner's Name
information is required for Osterville Ma. 02655 9/30/2010
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.
❑ ® 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Tower hill Rd.
Property Address
Mary Jane &John Savage
Owner Owner's Name
information is
required for Osterville Ma. 02655 9/30/2010
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?
® ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 116 Tower hill Rd.
Property Address
Mary Jane&John Savage
Owner Owner's Name
information is required for Osterville Ma. 02655 9/30/2010
every page. City/Town 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
Seasonaluse? ❑ Yes ® No
:53,000
Water meter readings, if available (last 2 years usage (gpd)): 2002008:53,000
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 9/30/2010
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
L r
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 116 Tower hill Rd.
Property Address
Mary Jane &John Savage
Owner Owner's Name
information is required for Osterville Ma. 02655 9/30/2010
every 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:
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 116 Tower hill Rd.
Property Address
Mary Jane&John Savage
Owner Owner's Name
information is required for Osterville Ma. 02655 9/30/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1994
-Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: e0+
t
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of leakage.system vented through the house vents.
Septic Tank (locate on site plan):
Depth below grade:. 1.5'
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000
Sludge depth:
1"
t5ins-09/08 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
116 Tower hill Rd.
Property Address
Mary Jane&John Savage
Owner, Owner's Name
information is required for Osterville Ma. 02655 9/30/2010
every 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
31"
Scum thickness
1"
Distance from'top of scum to top of outlet tee or baffle
7"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 116 Tower hill Rd.
Property Address
Mary Jane &John Savage
Owner Owner's Name
information is required for Osterville Ma. 02655 9/30/2010
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.):
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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Tower hill Rd.
Property Address
Mary Jane &John Savage
Owner Owner's Name
information is required for Osterville Ma. 02655 9/30/2010
every 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 No
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.no evidence of leakage.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Tower hill Rd.
Property Address
Mary Jane &John Savage
Owner Owner's Name
information is required for Osterville Ma. 02655 9/30/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ 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.):
Sandy soil.System shows signs of hydraulic failure.Water level was 4" below invert at time of
inspection.
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-09/08 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
116 Tower hill Rd.
Property Address
Mary Jane&John Savage
Owner Owner's Name
information is required for Osterville Ma. 02655 9/30/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 116 Tower hill Rd.
Property Address
Mary Jane&John Savage
Owner Owner's Name
information is required for Osterville Ma. 02655 9/30/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of LP 30'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
As-built
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
thins•09/08 Title 5-official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
f/
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
116 Tower hill Rd.
Property Address
Mary Jane&John Savage
Owner Owner's Name
information is required for Osterville Ma. 02655 9/30/2010
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
oFVia
Town of Barnstable P#
SZ
Department of Re, gulatory Services
BAM&MBU, : Public Health Division 'Date
t6J9 ,6� 200 Main� Street,Hyannis MA 02601 iOrED�A �• d , '
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Date Scheduled DZ20 '
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A� Time� Fee Pd. '` � a
Soil SuitabiI Arse sment for Sewa a is o g p sal
Performed By: ` r
Witnessed By:
;
Location Address
LOCATION& GENERAL INFORMATION
Owner's Name S'A j A in r
P16 (vc�leT t-I(il 2p � r�PQy- A4Ie-
O S'Ter✓t/!to M4• o A 6x.5- Address
Assessor's Map/Parcel ��/� _ O.2 Q Engineer's Name YA j►(ee k r✓e 7,
NEW CONSTRUCTION REPAIR /qA✓-e WtA-s P.;l
Telephone# .9 g_ d 8._ a O,
Land Use Slopes(90)
t t 4 Surface Stones
Distances from: Open Water Body ft ' Possible Wet Area +
ft Drinking Water Well ft
Drainage Way ft Property Line ft Other ~
• ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes)
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Parent material(geologic) Depth to Bedrock
Depth to Groundwater. Standing Water in Hole:
Weeping from Pit Face
Estimated Seasonal High Groundwater
Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE
Depth Observed standing in obs.hole: in. Depth to soil mottle:
Depth to weeping from side of obs.hole: In, Groundwater Adjustment
ft
!'ex Well# Reading Date: Index Well level Adl,factor ter Adj
Adj.Groundwater Level,
I PERCOLATION TEST batty Thee_ -
Observation
Hole# Time at 9" _
Depth of Perc
Time at 6"
Start Pre-soak Time @
Time(9"-6")
End Pre-soak
u !
Rate Min/Inch t 1t
F+,
Site Suitability Asr;essmen[ Site Passed Site Failed:. `
Additional Testing Needed(YIN)
i f i
Original: Public'Health Division 1 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:ISEPTICIP f iRCFORM.DOC
1
i
DEEP.OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
on istenc %Gravel)
17
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consi ten % el
414 -
-DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Grave
1 �
4 i
k
DEEP OBSERVATION HOLE LOG Hole#'
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.
Fi A Insurance Rate Man: .
Above 500 year flood boundary No— Yes
Within 500 year boundary No v'/Yes
• V _
WilL in 100 year flood boundary No,— Yes .
Depth of Nahtraly Occurring Pervious Material
Does at least four feet of naturally occurring perv' ial exist in all areas observed throughout the
area proposed:for tiie soil absorption system?
If not,what is the depth f naturally occurring pery ous material? '
Certificatio5.,i h D`
I certify that on U (date)I have passed the soil evaluator examination approved by the
Department of Envir n en I Protection and that the above analysis was perfor ed b me consistent with .
the required trainin ,exp se d xperience described in 310 CM'
15.017.
Signal ur Date (� v
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local food service establishments to equip all hand wash sinks and all bathroom sinks
with touchless sensor operated faucet devices.
The new deadline is June 30, 2008. Please make arrangements to comply with this
Regulation on or before the established deadline.
If you should have any questions,please telephone the Health Division at 508-862-4644.
PER ORDER OF THE BOARD OF HEALTH.
Wayne Miller,M.D.
Paul Canniff, D.M.D.
Junuchi Sawayangi
gAtouchless faucets for restaurants.doc
ry
C/ TOWN OF BARNSTABLE
III LOCATION fo1,ua 4 SEWAGE # 9y 3fD
[a
VILLAGE o5 re'R t//L G,.? ASSESSOR'S MAP & LOTI
INSTALLER'S NAME PHONE NO. .J J. /11 A C O M lie JP 7 O.y_
SEPTIC TANK CAPACITY p p�
LEACHING FACILITY:(type) P!r (size) /. D D U
NO. OF BEDROOMS -3, .PRIVATE WEL'L.OR PUBLIC WATER
r OR OWNER
DATE.PERMIT ISSUED: leg,
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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No................&=M Fas...$....
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COMMONWEALTH OF MASSACHUSETTS
CM
��- �? ,,. BOARD OF HEALTH
Signed Date TOWN OF BARNSTABLE plql Oa s �-
Appfiratiuu for Mitipuittl Wor1w Tomitrurtiurt Errant
Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal
..Sy.-stem at:
116 Towerhill Road Osterville
--------------------------•-••--....--------........----•--••------------------..........--.------ --••---••-----•-----••••••-----•---••••--•-•-•---------•------------....------------------.....---
Location.Address or Lot No.
MaryJane...Savage....................................................
W J.P.Macomber Jr. Owner Address
Installer Address
PQ
VType of Building Size Lot............................Sq. feet
DwellingX-X No. of Bedrooms..............3.._--_.._..-._..-_._.-....-Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e 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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
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'+ -----------------------•-----•-----•---•--••-------•----•-•--•--•---•----•-••--••--•--••-•-•.......•.........................................................
O Description of Soil.......Sand & Gravel
x
w
-------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------•••.
M. Nature of Repairs or Alterations—Answer when applicable------ftit;-.... �e.s•spool .....Install_.._-1-_ 000...gallon
tank 1-distribution box_ 1-1000 gallon leaching pit hacked in stone.
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 Compliant .has been is ed the b and of heal .
Signed ------ ...... 0 6/21/9 4
..... ........ ......Da[e.................
Application Approved By ----------------a ..... .. ... 'j�(2...........-----......---------------- .............. ....... '"
`y Date
Application Disapproved for the following reasons: ....................................... -.-........... ..- .........- ......---..................
..... .......................................................................
qqDa
Permit No. .............l.......�-- ��--------------- Issued
Dare
f
No.................=...... Fmc $....3
THE COMMONWEALTH OF MASSACHUSETTS
Ci
yBOARD OF HEALTH
TOWN OF BARNSTABLE p / q/ c-
ApVtiratiuii for Ui_npasal Works Cnuntrnrtiun Permit
Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal
System at:
116 Towerhill Road Osterville
..... -•.. ............. --- •-- ---
Location-Address or Lot No.
Mary Jane Savaqe
------------------------•-----------• ---.•-...---- ......
W J.P.Macomber Jr. Owner Address
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling, No. of Bedrooms______ ______3______________________-___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. 1________________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........................
a ---••--------••-----------------•---•••-----•--••---------••-----•----•----••..............................................................................
0 Description of Soil__._..-Sand & Gravel
x
w
UNature of Repairs or Alterations—Answer when applicable._-__-Omi_t--•Cesspool . _Instal•l. .1-m000...gallon
tank 1—distribution box 1-1000 gallon leaching pit pacicecl in stone.
-•--------------------------•-----------------------------------------------------------•------....--------------------------------------------------------------------------•-----....................
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 Complianc�haSeen issrledl y the board of healt .
Signed ............ V,
--/21/9 4
U. !^ -- Date y
Application Approved BY .. v �._�-e__ - ..: ...
Application Disapproved for the following reasons- -------------------------------_-------------------------.-----------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ........................................
......-................
Da te
Permit No- ------------/. /._-4 �� --1 -------------- Issued
Date
—. -_.:-----.-----..--.._--._.------_..—_.— ---.------------. ..,_Ps _.------------------------.—._---_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifirate of CIlIImplian e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX)
by .---J.P.Macomber Jr .
Installer ------
116 Towerhmll Road Osterville
at ------------------------------------------------------------------------------------------------------------- -------- -------------------------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State_Environmental Code as described in
the application for Disposal Works Construction Permit No. __ .�-f_..^ �_``�.... dated -------------_._------------.-.._.-----_.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
,i � Ins Inspector "
DATE --- " -- - - ---- -
------- _-
d.
---------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
pp TOWN OF BARNSTABLE
No.... FEE-- .. �.:.�?9.
�i��u��tl urk� �un�tr�rtiun �erutit
J P.Macomber Jr.
Permissionis hereby granted..............................................................................................................................................
to Construct (� ) or Repair X � an Individual Sewage Disposal System
116 `rowerhill itoad Osterville
atNo........................................_---_------------_--- -------------------------------------- ---------------------------------------------------------------------•---•-•-•••-•---
Stree
as shown on the application for Disposal Works Construction Permit tNo-�7. _�Dated.__.___r__ �_�_..-_
................................. . ......................................................
l / Board of Health
DATE Y :--.[y/
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS p
NOTE: x DENOTES SPOT ELEVATIONBA
3s
Cyr
F
BENCHMARK: CENTER OF CB RIM TOWER HILL ROAD
ELEVATION: 98.42'
DATUM: ASSIGNED g
10.6ft
�r ~� 61 .73' ^ 4sLarvflle
PROPOSED INFILTRATOR 1 8f�- S 89°45'5Q0 - E— '
CHAMBERS IN FIELD �� / DTP 2
CONFIGURATION 1 . P o #1 04
WITHOUT AGGREGATE v �Q°J — Add ?
--'� EXISTING LEACHPIT m pguest s
. , _ ;;tx ". .. I ,6'1mgMapQuq�HPMfen.r,�Mio nnvleo lmenW..
.3ft PROPOSED PVC CLEANOUT LOCUS MAP
1 3.8ft EXISTING 1000 GALLON, TANK PLAN REF 82-93
TO REMAIN DEED REF 12010-96
SdE GENER L /�i�i�����/i���//�i 1 1 .Oft ASSESSOR'S' MAR- 141-29
/////////////////////
NOTE #11 ///////////////// ZONING.- RC
#11NOTE: EXISTING SYSTEM COMPONENTS SETBACKS.- 20'-10'10'
ARE DRAWN PER TOWN OF BARNSTABLE FLOOD ZONE- C
C-4 AS-BUILT CARD. PANEL NUMBER.- 250001 0016 D
OF Mq DATED.- 07 02 1992
���� DAVID ss�� OVERLAY DIST.• CP, HT,,RPO ZONE n
'. 'ft s SALT WATER ESTUARUES
O B G
EDGE OF ROAD .�� " ' """ 1'
EDGE OF SIDEWALK PLOT PLAN OF LAND
q �• ///////// �. C�'=��_ LOCATED AT
0 116 TO WER HILL ROAD
Q o
OSTER VILLE. MA
26.4ft
f 20226.2 SQ. FT.
Qz— ti 0.46 ACRES
0 29 �, <�o�P�G1S cnF�G��� 7 PREPARED FOR.
0 o AS/LOTsrEeNFN JOHN F. SA VAGE
77 Qo 2r
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0.
Y'' '` b OCTOBER 31, 2010
>16
REV NOVEMBER 3, 2010
z J o REV-
AS/LOT
AS/LOT o+ 44.75T 50„ W REV-
,30 s 82 37 YANKEE LAND SURVEY
GRAPHIC SCALE
cp 30 so CO., INC.
AS/LOT 119 ROUTE 149
24 MARSTONS MILLS, MA 02648
1 inch = 30 ft. TEL• 508-428-0055 FAX 508-420-5553
YAI7=URVEY6C0MCAST.NET WWW.YAA0M SURVEY.COhf
SHEET 1 OF 1 JOB # 54684 SH
SEWAGE SYSTEM- PROFILE VIEW N . T . S .
}
T.O.F. EL. 105.8'
fFIN GRADE = 104't
RISERS FIN GRADE = 102't .
20" 20" -
INV EL. DIX DIA PVC INSPECTION PORT WITH SCREW CAP
103.2' GEOTEXTILE FABRIC TO WITHIN 3" OF FINISHED GRADE 4 TYP RISER FIN GRADE = 101't ( )
SEE PLAN VIEW.
10" MIN. f 14" MIN. INV EL EL.98.70'
-\ �- EXIST. TO INV EL
BELOW FLOW LINE REMAIN INV EL. MIN. 6" INV EL. o o ° D o e ° o
F-rl
98.72' SUMP 98.52' 98.37' } o 0 0 0 0 IN
LIQUID LEVEL 48" 1 6��o 0 0 o ° u o° u o° o Q
GAS BAFFLE
6 STONE o 0 0 0 o a o 0
DISTRIBUTION BOX o° ° o 0 o EL97.3T
EXISTING 1000 GALLON TANK CLEAN MEDIUM SAND
J PRECAST'REINFORCED CONCRETE DISTRIBUTION BOX 34+' 6" SEPARATION BETWEEN ROWS (TYP.)
INSTALL"ON A LEVEL BASE WITH WATERTIGHT COVER. 1 3.83
MINIMUM WALL THICKNESS = 2" ^n
TEES SHALL BE CONSTRUCTED OF SCHEDULE 40 PVC AND SHALL EXTEND A MINIMUM INSIDE DIMENSION = 12" USE FOUR ROWS OF (4) HIGH CAPACITY INFILTRATOR CHAMBERS
MINIMUM OF 6" ABOVE THE FLOW LINE OF THE SEPTIC TANK AND BE ON OUTLET INVERTS SHALL BE EQUAL TO EACH OTHER AND AT TOTAL CHAMBERS = 16
THE CENTERLINE OF THE SEPTIC TANK LOCATED DIRECTLEY UNDER THE 2" MINIMUM BELOW INLET INVERT.
CLEAN-OUT MANHOLE. THE DISTRIBUTION LINES FROM THE DISTRIBUTION BOX SHALL ALL HAVE
THE INLET PIPE ELEVATION SHALL BE NO LESS THAN 2" NOR MORE THAN 3" EQUAL INVERTS AS DETERMINED BY FLOODING THE DISTRIBUTION BOX TO PERFORM 5' STRIPOUT
ABOVE THE INVERT ELEVATION OF THE OUTLET PIPE. THE HEIGHT OF THE DISTRIBUTION LINE INVERT AFTER ALL LINES HAVE DOWN TO C1 HORIZON BOTTOM OF SOIL PIT = EL. 92.0'
SEPTIC TANK SHALL HAVE A MINIMUM COVER OF 9" BEEN SEALED IN PLACE. NO GROUND WATER OR
TWO MANHOLES WITH READILY REMOVABLE IMPERMEABLE COVERS INVERT ADJUSTMENTS SHALL BE MADE BY FILLING WITH DURABLE AND REDOXIMORPHIC FEATURES OBSERVED
OF DURABLE MATERIAL SHALL BE PROVIDED WITH ACCESS PORTS. NONDEFORMABLE MATERIAL PERMANENTLY FASTENED TO THE LINE OR
RISERS ADDED AS MAY BE REQUIRED RECONSTRUCTING THE LINES UNTIL ALL INVERTS ARE OF EQUAL ELEVATION.
THE OUTLET TEE SHALL BE EQUIPPED WITH GAS BAFFLE.
ANY AT-GRADE COVERS SHALL BE SECURED TO UNAUTHORIZED ACCESS.
DESIGN DATA:
EXISTING THREE BEDROOMS — NO INCREASED FLOW
SEPTIC TANK CAPACITY: 3 X 1 10 = 330 GPD REQUIRED FLOW 4" PVC
REQUIRED — 330 GALLONS AT 200% VENT
PROVIDED — 1000 GALLONS M
USE 16 HIGH CAPACITY INFILTRATOR CHAMBERS
IN FIELD CONFIGURATION WITHOUT AGGREGATE FIN GRADE = 100t
GENERAL NOTES: (16 X 6.25) X 4.72 SF/LF = 472 SF EL.98.70'
1 . ALL THE WORKMANSHIP AND MATERIALS SHALL CONFORM TO DEP 472 X 0.74 = 349 GPD TOTAL DESIGN FLOW o a° o
TITLE V AND THE TOWN OF BARNSTABLE RULES AND REGULATIONS MED MED
RESERVE FLOW = 19 . GPD
FOR THE SUBSURFACE DISPOSAL OF SEWAGE. SAND -.AND
2. ACCESS PORTS OVER TANK TEES SHALL BE ACCESSIBLE WITHIN 6" GARBAGE DISPOSAL NOT ALLOWED °° 25 e°e°
OF FINISHED GRADE
3: ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF 26'
WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10"
OF DRIVES OR PARKING. H-20 LOADING SHALL BE USED UNDER OR WITHIN USE FOUR ROWS OF (4) HIGH CAPACITY INFILTRATOR 'CHAMBERS
TOTAL CHAMBERS = 16
10' OF DRIVES OR PARKING, UNLESS NOTED. I
tr> 4. THE EXCAVATOR/CONTRACTOR SHALL CALL "DIG SAFE AND VERIFY THE LOCATION T.P. #1 PERC <2 M/INCH T.P. #2 PERC <2 M/INCH
OF SITE UTILITIES PRIOR TO ANY EXCAVATION, AND SHALL BE RESPONSIBLE FOR EL. 103.3' EL. 103.0'
ALL MATTERS RELATING TO ELECTRIC AND/OR GAS EASEMENTS. 0" 0»
!� 5. SEWER PIPES SHALL BE SCHEDULE 40 PVC. (4" DIA. UNLESS UTHERWISE NOTED) "A" "LS" „ 4„"A" "LS"
6. ANY MASONRY UNITS USED TO BRING COVERS TO GRADE SHALL BE 4 SOIL DATA:
MORTARED IN PLACE. "FILL" "FILL" TEST DATE: 10/20/2010
7. FINISH GRADE SHALL HAVE A MINIMUM SLOPE OF 0.02 FT. PER FOOT. "B/Ao" "LS" 10 YR 6/8 "BAo" "LS". 10/' 'YR 6/8 SOIL EVALUATOR: B MASON
8. EXISTING LEACH PIT & DISTRIBUTION BOX SHALL BE ABANDONED PER 56" 56' APPROVAL DATE: DAVID DAVID
TITLE 5 REQUIREMENTS. EL. 98.6' EL. 98.3'
10/94
9. THE EXCAVATOR/CONTRACTOR SHALL BE RESPONSIBLE TO CONTACT YANKEE c1 C111 HEALTH AGENT: DAVID W STANTON
SURVEY 24 HOURS PRIOR TO ANY REQUIRED INSPECTIONS. "FS" 10 YR 6/6 "FS" 10 YR 6/6
10. ALL COMPONENTS SHALL BE MARKED WITH MAGNETIC TAPE OR EL. 92.3' 132" EL. 92.0' 132"
COMPARABLE MEANS IN ORDER TO LOCATE THEM ONCE BURIED.
NO G\WATER OR NO G\WATER OR
11 . WHEREVER WATER SERVICE LINE IS CLOSER THAN 10' TO A SYSTEM REDOXIMORPHIC FEATURES REDOXIMORPHIC FEATURES
COMPONENT, SAID WATER SERVICE LINE SHALL BE SLEEVED IN PVC, OR RELOCATED. 54684
. SHEET 2 OF 2 JOB NUMBER_______