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HomeMy WebLinkAbout0214 TOWER HILL ROAD - Health�I I o r 4 Commonwealth of Massachusetts' - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �i 214 TOWER HILL ROAD Property Address CHRISTINE G. LOFTIN Owner Owners Name information is required for every 0 TERVILLE MA 02655 11/3/09 . 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. Important:When filling out forms A. General Information , on the computer, Y J- use only the tab 1. Inspector: key to move your cursor-do not JAMES D SEARS use the return key. Name of Inspector BLUEWATER Company Name 350 MAIN ST Company Address W.YARMOUTH: MA 02673 t City/Town State Zip Code 508-775-2800 S-1623 Telephone Number License Number f. cc g � B. Certification I certlfythat I have personally inspected thesewage disposal system:at this address and that the y, information reported below is true, accurate and complete as of the time of the inspection. The inspection ca -�- was pe 86ed based on'my training and experience in the proper function and maintenance of on site .. o sewa e; ,,5 osal systems. I am a DEP approved system inspector pursuant to Section 15.340 of pP Y P Title 5(310 CMR 15.000).The system: o )ca `"' ❑x Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11/3/09 Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall'submit the report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future u der the same or different conditions of use. I .I Commonwealth of Massachusetts _'. Title 5 Official Inspection Form �p Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 214 TOWER HILL ROAD Property Address CHRISTINE G. LOFTIN Owner Owner's Name information is required for every OSTERVILLE MA 02655 11/3/09 page. Cityrrown 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: X R x❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 13 System Conditional) Passes: Y Y ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined(Y, N, ND) in the❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.- System will pass inspection if the existingtank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not.leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed i Commonwealth of Massachusetts ...__........ Title'. 5 Official Inspection Form �C, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 214 TOWER HILL ROAD Property Address CHRISTINE G. LOFTIN Owner Owner's Name information is required for every OSTERVILLE MA 02655 . 11/3/09 page. Cityrrown State Zip Code Date of Inspection B. Certification (cone:) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more,than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the.Board of Health): El broken pipe(s)are replaced. ❑ obstruction is removed ND Explain: . C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine ' if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: , ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated,wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The,system has a septic,tank and SAS and the SAS is within a Zone 1 of a public water supply.' 1 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .✓ 214 TOWER HILL ROAD Property Address CHRISTINE G. LOFTIN Owner Owner's Name information is required for every OSTERVILLE MA 02655 11/3/09 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"*. Method used to determine distance: '*This system passes if the well water analysis, performed at a DEP certified.laboratory, for coliform bacteria-indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5'ppm, provided that no other failure criteria are triggered:A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: X You must indicate"Yes".or"No"to each of the following for all inspections: Yes No El x❑ 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 El Fx_1 or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less El EXI than Y2 day flow 0 Required pumping more than 4 times in the last year NOT due to clogged or ' obstructed pipe(s). Number of times pumped:' ❑ x❑ Any portion of the;SAS, cesspool or privy is below high_ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Commonwealth of Massachusetts 5, Title 5 Official Inspection F®rn ii Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments 214 TOWER HILL ROAD Property Address CHRISTINE G. LOFTIN Owner Owner's Name information is 02655 11/3/09 required for every OSTERVILLE MA ` page. City/rown State Zip Code Date of Inspection B. Certification-(cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No p x❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ 0 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 ❑ 0 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 iodated 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments --/✓ 214 TOWER HILL ROAD Property Address CHRISTINE G. LOFTIN Owner Owners Name information is required for every OSTERVILLE MA 02655 11/3/09' page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no" as to each of the following: Yes No Z ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? ❑ 0 Has the system received normal flows in the previous.two week period? P ❑ Z Have large volumes of water been introduced to the system recentlyor as part of this inspection? 0 ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) 0 ❑ Was the facility-or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, including the SAS, located on site? 0 ❑ Were-the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles'ortees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? 0 ❑ 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: p ❑ Existing information. For example, a plan at the Board of Health. ❑ 0 Determined in the field(if any of the failure criteria.related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] r - ' Commonwealth of Massachusetts 1RR Title 5 Official Inspection Form �; _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 214 TOWER HILL ROAD Property Address CHRISTINE G. LOFTIN' Owner Owner's Name - information is required for every OSTERVILLE MA 02655 11/3/09 page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): unknown Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x.#of bedrooms): unknown . Number of current residents: 0 Does residence:have a garbage grinder? ❑Yes 0 No Is laundry on a separate sewage system?[if yes-separate inspection required] ❑Yes x❑ No Laundry system inspected? ❑Yes ❑ No Seasonal use? ❑x Yes ❑ No Water meter readings, if available last 2 ears usage 05-46.5 gpd. 9 ( Y 9 (gpd)): 06-32.8 gpd Sump pump? ❑Yes X❑ No Last date of occupancy: SEASONAL. Date Commercial/Industrial Flow Conditions:. Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? A, ❑Yes ❑ No Industrial waste holding tank present? ❑Yes ❑ No Non-sanitary waste discharged to the Title 5 system? Dyes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form Not for Voluntary Assessments 214 TOWER HILL ROAD Property Address CHRISTINE G. LOFTIN Owner Owner's Name information is required for every OSTERVILLE MA 02655 11/3/09- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: NONE PER BOH Was system pumped as part of the inspection? ❑Yes 0 No If yes, volume pumped: . gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system. X❑ Single cesspool 0 Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: UNKNOWN Were sewage odors detected when arriving at the site? ❑Yes 0 No Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form=,Not for Voluntary Assessments 214 TOWER HILL ROAD' Property Address. CHRISTINE G. LOFTIN Owner Owner's Name information is required for every OSTERVILLE MA 02655 11/3109 page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) Building Sewer(locate on site plan): Depth below grade: 26"feet Material of construction: ❑cast iron X❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): CAMERA LINES AND THEY ARE CLEAN &SOLID Septic Tank(locate on site plan). Depth below grade: 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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Commonwealth of Massachusetts 111R Title 5 Official Inspection Form�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments % 214 TOWER HILL ROAD Property Address CHRISTINE G. LOFTIN Owner Owner's Name information is OSTERVILLE MA 02655 11/3/09 required for 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.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: f Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ` Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass El polyethylene ❑other(explain): Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments . % 214 TOWER HILL ROAD Property Address CHRISTINE G. LOFTIN Owner Owner's Name information is required for every OSTERVILLE 'MA 02655 1113/09. page. Cityrrown State Zip,Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) ' Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑Yes ❑ No Alarm level: Alarm in working order. Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? '❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and-distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: []Yes ❑ No Alarms in working order: ❑Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection, Form i i' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -- '' 214 TOWER HILL ROAD Property Address CHRISTINE G. LOFTIN Owner Owner's Name information is required for every OSTERVILLE MA 02655 11/3/09 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavationnot required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: xp overflow cesspool number: 1 ❑ innovative/alternative system Type/name of technology Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): THE OVERFLOW CESSPOOL WAS DRY AND SHOWED NO SIGNS OF HYDROLIC FAILURE OR PONDING. C Commonwealth of Massachusetts o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 214 TOWER HILL ROAD Property Address CHRISTINE G. LOFTIN Owner Owner's Name information is OSTERVILLE MA 02655 11/3/09 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 2-6X8 Depth—top of liquid to inlet invert 51+ Depth of solids layer 3" Depth of scum layer 0ff Dimensions of cesspool 6X8 Materials of construction INDIVIDUAL BLOCK Indication of groundwater inflow E]Yes 0 No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 1'WATER AND NO SIGN OF OVER LOADING. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding; condition of vegetation, etc.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `f 214 TOWER HILLROAD Property Address CHRISTINE G. LOFTIN Owner Owner's Name information is required for every OSTERVILLE - MA 02655 11/3/09 page: Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch'Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks orbenchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. F r -4D � 3 y fi+la5 9nn6 blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewaqe Disposal System Commonwealth of Massachusetts . Title 5 Official Inspection Form IIci Subsurface Sewage Disposal System Form -Not for Voluntary Assessments --,,, 214 TOWER HILL ROAD Property Address CHRISTINE G. LOFTIN Owner Owner's Name information is required for every OSTERVILLE MA 02655 11/3/09 page. Cityrrown State Zip Code Date of Inspection D. System Information (cbnt.) Site Exam: Check Slope MINOR X❑, Surface water, NONE x❑ Check cellar DRY Shallow wells NONE Estimated depth to hlgh'ground water; 26' PER REPORT DATED 8/24/99 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, pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health=explain: El Checkedwith local excavators, installers-(attach documentation) x❑ Accessed USGS database explain: MIW 29 ZONE A 0-2 L'EVEL 9.7 ADJUSTMENT=5.3' You must describe how you established the high ground water elevation: SEE ATTACHED . 214 TOWER HILL RD OSTERVILLE.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 f1� r I 1 1 I , I. ' 1 � 1 bm1 0 m01 �3i 1 , 1J _ CI --1 bo C m0 o 0 j �I -O' r { Proposed Changes: James & Mary Gallagher Construct addition on southerly gable of existing structure 12'x M 214 Tower Hill lid. Interior changes,add new walk in a: modify bathroom,and laundry area. �p Gsterville, a. 02655 . Expand kitchen. I i I m GARAGE `^ ZV.4"x1sr 1: F � _• it { ..J . 3M 1 � 5 b i FAMILY 4 •� 1a•-r x e••r t i I LAUNDRY i I W-1-x 9•-r KITCHEN ! R l 1--2 lln I MASTER BATH 6'-1"x T-8"a q LIVING � t3••r x t5•-9" ' i MASTER BDRM 11�40'x 14'-0" I ENTRY I { rrxe's s.Q Ys ----- ---—-- 43-4 — ------ --- -� �r C. t a il:�h tri ;i. ii r t i.•1 _�.t lk;E .... 3JIl{ rt{ ,.._ _. ,,�?;'RATE i�cli�{{{T IS RcL`'�.UIhrJ t: Tom. _,-., .,.,vcn�rFl:r(lR5-THEELECTRIC.AL f - Proposed 12" x 22® Addition 0 26'-7" kk(- V-4 7/8" 12'-0 3/4" i I New E LAUNDRY x 5'-6" ZD Bo1Co � E t� ENTRY "' 6.�,'x 10'-7" "rare r e rL MASTER BATH ---- N 11'-3"x 8-2" co I ! jk M r I Imo _ it � II II II II v - - - r- - - - - - - - - - -- CLOSET + I 11"-3"x 6'-6" I C I ao I I II I - i � Remove stairs Inflll floor I r Proposed Foundation - - - - - - - - - - - -v I I I I--- - - - - - -- - L-A I ----6'-0" ---- I I 1 r 4 I I — - —12'-1 13116' -- —— ---= - `- c i II II i j it 11 � -- -- - - - - -- -- --- • 1 � � (�Ai15 CP 12'-1 — ' 6'-6" _—____ cA.)SLJ Match Eisgng Ftdl Wag licight \/� ��••��(y A)t • GRADE — �� / f 2"X 6"TREATED SILL PLATE SILL SEAL H7'ANCHOR DOLTS 6'O.C. 8"POURED CONCRETE Wl VERTICAL REINF(IF REQUIRED) DAMP PROOFING ITO GRADE) 4"CONCRETE FLOOR 6"X 16"CONT_CONCRETE FOOTING - -•-----RE-BAR(2) - Wl WIRE MESH OPTIONAL Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on thisform. Inspection forms may not be altered in any way. A. General Information Important: When tilling out 1. Property Information: . forms on the computer, use 214 TOWER HILL ROAD OSTERVILLE only the tab key Property Address i to move your CHRISTINE G. LOFTIN' 1 ' o.V-2 cursor-do not use the return Owners Name key. 36 MADAKET RD. Owner's Address NANTUCKET' MA 02554 City/Town State Zip Code „ Date of I_spection:•_ 11-21-07 n Date 2. Inspector: I MICHAEL A. BURNIE Name of Inspector bluewater/burniei Company Name cn V 350 MAIN ST. _ Company Address . rt W. YARMOUTH MA 0267S= City/Town State Zip Cc6b • � r 508-775-2800 Telephone Number. B. Certification - certify that l 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..l am_a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® .Passes ❑. Conditionally Passes ❑ 'Fails X\�+�H OF El Needs Further Evalua 'on by the Local Approving Authority 11-21n-07 a ' MICHAEL" Inspector's Signat Date ;a —) A' BURNIE The system inspector shall submit a copy of this inspection report to the AV i ' Autfl � 8ard of Health or DEP)within 30 days of completing this inspection. If the systerw or, has a design flow of 10,000 gpd or greater, the inspector and the system owns* j 11111 he 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 dhow the system will perform in the future under the same or different conditions of use. title5 2006 blank.doc a 03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System — Page 1 of 1.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 214 TOWER HILL ROAD Property Address OSTERVILLE MA 02655 City/Town State Zip Code - CHRISTINE G. LOFTIN 11-21-07 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below:: Comments: . B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined(Y,,N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate' of Compliance indicating that the tank,is less than 20 years old is available. ND Explain: itle5 2006 blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form 'I Not for Voluntary Assessments Subsurface Sewage Disposal System Form GSM B. Certification (cont.) 214 TOWER,HILL ROAD Property Address OSTERVILLE MA- 02655 City/Town State Zip Code CHRISTINE G. LOFTIN 11-21-OT Owner's Name Date of Inspection 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 ❑ obstruction is�removed. ❑ distribution box is leveled or replaced ND Explain: .The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with'approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 titles 2006 blank.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 I Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 214 TOWER HILL ROAD Property Address OSTERVILLE MA 02655 City/Town State Zip Code CHRISTINE G. LOFTIN 11-21-07 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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 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: titles'2006_blank.doc•03/2006 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ^M Subsurface Sewage Disposal System Form B. Certification (cont.) 214 TOWER HILL ROAD Property Address OSTERVILLE MA 02655 Cityrrown State ZipCode CHRISTINE G. LOFTIN 11-21-07 Owner's Name Date of Inspection D)System Failure Criteria Applicable to All Systems' You must indicate "Yes" or"No"to each of the following for all inspections: Yes No, El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less ❑ ® than M day flow ® Required pumping more than 4 times in the last year NOT due to clogged or . obstructed pipe(s). Number of times pumped: ❑ Z 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 of 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. Yes No El Z The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. titles 2006 blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Ina Title 5 Official Inspection Form Not for Voluntary Assessments ; Subsurface Sewage Disposal System, Form p G M B. Certification (cont.) 214 TOWER HILL ROAD . Property Address OSTERVILLE MA 02655 City/Town State Zip Code CHRISTINE G. LOFTIN 11-21-07 Owner's Name Date of Inspection E Y Large Systems: To be considered a largeY s stem the system must serve a facility with a Y _ 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 a ® 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. title5 2006_blank.doc•0312006 Title 5 Official Inspection.Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 7y C. Checklist 214 TOWER HILL ROAD Property Address OSTERVILLE MA 02655 City/Town State Zip Code CHRISTINE G. LOFTIN . 11-21-07 Owner's Name Date of Inspection 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? ® O 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 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 system s 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)] title5 2006 blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System /, Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System. Form 1y D. System. Information 214 TOWER HILL ROAD Property Address OSTERVILLE MA 02655 City/Town State Zip Code CHRISTINE G. LOFTIN 11-21-07 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): unknown Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): UNKNOWN 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No- Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 05-32.5 GPD 9 ( Y 9 (gP ))� 06-32.8 GPD Sump pump? ❑ Yes ® No SEASONALY Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons perday-(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 214 TOWER HILL ROAD Property Address OSTERVILLE MA 02655 City/Town. State Zip Code CHRISTINE G. LOFTIN 11-21-01 Owner's Name Date of Inspection General Information Pumping Records: Source of information: NONE PER BOH Was system pumped as part of the inspection?. ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ® Single cesspool ® Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval., ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information UNKNOWN Were sewage odors detected when.arriving at the site? ❑ Yes,® No titles 2006 blank.doc•08/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 9 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4 M D. System Information (cont.) 214 TOWER HILL ROAD Property Address OSTERVI LLE MA 02655 Cityrrown State Zip Code CHRISTINE G. LOFTIN 11-21-07 .Owner's Name Date of Inspection 'Building Sewer(locate on site plan): 2611 Depth below grade: feet Material of construction:- ❑ cast iron ❑ 40 PVC ORANGEBURG ® other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): " Septic Tank(locate on site plan): Depth below grade: 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 Yes ❑ No certificate) Dimensions: - Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom ofscum to bottom of outlet tee or baffle How were dimensions determined? title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts 4 Title 5 Official Inspection . Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M De System Information (cont.) 214 TOWER HILL ROAD Property Address OSTERVILLE MA 02655 City/Town State Zip Code CHRISTINE G. LOFTIN 11-21=07 Owners Name Date of Inspection 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. 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 inspectio n) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): title5_2006_blank.doc a 03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 C� Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M D. System Information (cont.) 214 TOWER HILL ROAD Property Address. - OSTERVILLE MA. 02655 City/Town State Zip Code CHRISTINE G. LOFTIN 11'-21-07 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design.Flow: gallons per day w 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? ElYes ❑- No Distribution Box(if present must be opened) (locate on site plan): 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order; ❑ Yes ❑ No titles 2006 blank.doc.03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 12 of 16 I - Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage.Disposal System Form 4 H D. System Information (cont.) 214 TOWER HILL ROAD Property Address OSTERVILLE MA 02655 Cityrrown State Zip Code CHRISTINE G. LOFTIN 11-21-07 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site,plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ Teaching fields number,dimensions: ® overflow cesspool number: 1 ❑ innovative/alternative system Type/name of technology: Comments(note condition,of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation;etc.): THE OVERFLOW CESSPOOL WAS DRY AND SHOWED NO SIGNS OF HYDRAULIC FAILURE OR PONDING. titles 2006 blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form_ Not for Voluntary Assessments Subsurface Sewage Disposal System Form 7M D. System Information (cont.) 214 TOWER HILL ROAD Property Address OSTERVILLE MA 02655 Cityrrown State Zip Code CHRISTINE G. LOFTIN ' 11-21-07 Owner's Name Date of Inspection Cesspools (cesspool must be pumped•as part of inspection) (locate on site plan): Number and configuration 2-6X8 Depth—top of liquid to inlet invert 5'+ 3" Depth of solids layer 0" Depth of scum layer o Dimensions of cesspool 6X8 Materials of construction INDIVIDUAL BLOCK Indication of groundwater inflow. ❑ Yes ® No Comments(note condition of soil, signs of hydraulic failure, level of ponding;condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): - title5_2006_blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form` D. System Information (cont.) 214 TOWER HILL ROAD - Property Address OSTERVI LLE MA 02655 City[Town State Zip Code CHRISTINE G. LOFTIN 11-21-07 Owner's Name ' Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. 7 / S . o C a titles 2006 blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System o Page 15 of 16 • Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 7N D. System: Information (cont.) 214 TOWER HILL ROAD Property Address OSTERVILLE MA 02655 City/Town State Zip Code CHRISTINE G. LOFTIN 11-21-07 Owner's Name Date of Inspection Site Exam: Slope /�nfllY Surface water i(/&Pe Check cellar /)!y Shallow wells /a Estimated depth to ground water: �G 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: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: MIW 29 ZONE A 0-2 LEVEL 9.7 ADJUSTMENT=5.3' You must describe how you established the Thigh ground water elevation: SEE ATTACHED titles 2006 blank.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 i �au r y � - �+�F� . � `�"` � i � i _$ r•^.: r• t Y� F . t.. �I i i _ _ . i" i t r �. f <r�- _`� _ ��. � r/ t 6 � r` 1 1 t 1 \. j f t �. � ..._ ..-. _.... ....._ .. � I� �r i' � a � (� Town of Barnstable �p 1HE taY yP� Regulatory Services ,A ,STABLE ; Thomas F. Geiler,Director '16 9. •�� Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts,Department of Environmental Protection.- Although the Town of Barnstable Health Division received the original/co of this PY report; this Division does not warrant the functionality of the septic stem i Y y p y n the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved_ at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. lam . TOWN F BARNSTABLE , LOCAfl-OR',-d// i¢ SEWAGE # �//� ` . VIl.LAGE ��,��1�,��,-, �� ASSESSOR'S MAP& LOT " INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY IJoes LEACHING FACILITY: (type) (size) eAW NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: t Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Watei Supply Welland Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet f of Wetland and Lea hing Facility(If any ands exist githin 300 feet le cility) Feet ` d by I r 1 �� lower giti J No. . Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: k PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplication for Mis;po$ar *pgtem Cons;trurttott permit Application for a Perniit to Construct( ) Repair(Y4 Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. ��(�!-•� 111 k&_c Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 16 V41,-lu(, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: S► , Dwelling No.of Bedrooms 1 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) "w gpd Design flow provided — /V/ gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) st,,�J i 2. 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,of4e Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo Health. Signed Date _ /111� Application Approved by Date (/ —o Application Disapproved by: _ Date for the following reasons Permit No. tjC,ve, Date Issued 1 -t..4-« as f '. ,r .. .y . - .. v .. ;, .�,w. r l} .«+�J-�=`,` _ •C„ _ ,... � _ - r i\tY��v-ti S� _. -•-r FeeW:UV THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �V PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 21pplication for Miopo5ar *pgtemc Con5tructiou Permit Application for a Permit to Construct( ) Repair(Y-) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. PY IfIA1—t Owner's Name,Address,and Tel.No. 04, j� L jJ Assessor's Map/Parcel (Xj,_4L)l1 L Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. lie.t,ul-A ter- .l, vU Type of Building: Sj ,al }� ' Dwelling No.of Bedrooms '"!(V Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided — ,V rT gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 o e Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo He Signed + Date Application.Approved by Date Z- (j Application Disapproved by: _ Date _ ` for the following reasons Permit No. AS A Date Issued ———— —— —————————.——————— —— —————————— .,� THE COMMONWEALTH OF MASSACHUSETTS dN�� BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired Upgraded ( ) Abandoned( )by ) _ 1Jr- at i 11(lcD 0.r �u;kf has been constructed in cordance with the provisions of Title 5 and the for Disposal System Construction Permit No. a Do r S 5 dated Installer �(Ue lc/� Designer#bedrooms N Approved design A low '� „ gpd The issuance-of this-permit shall not be construed as a guarantee that the system wi 1 unllctiop as d�e/s.igne• �} W�L. Date a Inspector ��f ��� —�:'t .� —— ———— No. f�t7v�i 55 9 Fee $/Uy, (.b THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS 313igpoot *p!tem Construction Permit Permission is hereby granted to Construct ( ) Repair (X ) Upgrade ( ) Abandon ( ) System located at r;/ and as described in the above Application for Disposal System Construction Permit.The Vppl'icant 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-permit Date ��� _C Approved by DATE. 8/24/99 ---- PROPERTY ADDRESS:_214 Tow-p-r—-iI1-goad_-__ i Osterville Mass . 02655 ------------------------ f On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 2-6 ' x8 ' block cesspools . i Based on my inspection, I certify the following conditions: 2 . This is not a title five septic system. 3. This is sewage that is 40 yearsold and in proper,`. working order at this time. ro `�0 4 . Main cesspoo} is half full and the overflow . o� ry cesspool isya this time . ' t��aytis 9y SIGNATURE: f � 1�/ lf �- Name:_,L,L,- Macomber J1r--______ Company: Jose.2h_P. Macomber_& Son , Inc . Address:— Box—66 --- --------------- Centerville , Ma . 02632-0066 -------------------- Phone: 508_775_3338_______ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY rJOSEPH P. MACOMBER�& SCN, INC. Tanks-Cesspools-Leachfields Pumped & Installed Town Sewer Connectlons P.O. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 • i� SLX COMMONWEALTH OF M.A.SSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.6500 TRUDY CO Secret ARGEO PAUL CELLUCCI DAVID B. STRU Governor Co:n.^;iss:o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PtopertyAd&",: 214 Tower Hill Road NameofOwrw Ruth M. Cunnion Osterville024S79902655 Addeo"ofOwner: Date of 4upectfon: Nacne of 4upector:(Plaase Print),T n e c r,h A M G o m b e �Tr I am a DEP �Dpoved system Inspocta pur&u v t to Secoon `I6.'�40 of Tttfe 6 (310 CMR 15.000) Cornparty Name: J. Y.Macomber & Son Tnc _ M-ranAddrass: Rnx 66 Untervillo-,Mass . 02632 Telephone Number:50-7 CERTIFlCATION STATEMENT I certify, that I have personally Inspected the sewage disposal system at this address and that the Information reported below is true, accurate and complete as of the time of Inspection. The Inspecdon was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: �--� .s�..asde Conditionally Passes Needs Further Evalua ion By the Local Approving Authority _ Fails 4upector's Sjwwture: Date: The System Inspect shall submit a copy of this Inspection r port to the Approving Authority (Board of Health or DEP)within thirty 130) days o completing this Inspection. It the system Is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owns ' "ll submit the report to the appropriate regional office of the Dapanment ohfnvironmental Protection. The original should be sent to tns system owner•and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS • revised 9/2/98 Page Iof11 `� Printed on Recycled Taper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAddrass: 214 Tower Hill Road Osterville ,Mass . Own«: Ruth M. Cunnion Date of Inspection:8/2 4/9 9 INSPECTION SUMMARY: Check A, B, C, o/ A A. " SYSTEM PASSES: I have not found any information which Indicates that any of the failure conditions described in 310 CMR 1b.303 exist. Any failure .criteria not evaluated are Indicated below. COMMENTS: 8. SYSTEM CONDITIONALLY PASSES: .Ub 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. Indicate yes, no, or not determined(Y, N, or NO). Describe basis of daterminatlon In all Instances. If "not determined", explain why not. The septic tank Is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance (attached)Indicating that the tank was Installed within twenty (20) years prior to the date of the Inspection; or the septic tank, whether or not metal,Is cracked,structurally unsound, shows substantial Infiltration or exfiltration, or tank failure'is'Imminent. The system will pass Inspection if the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed In the distributloiibox Is due to broken or obstructed pipes) or due to a broken, settled or uneven d13tr1b6tl66'boz. The system will'pass inspection if(with approval of the Board of Ha&Ith). �.- broken pipes)are replaced obstruction Is removed distribution box Is levelled or replaced - The system required pumpMg•more thawfourtimes a•yeardue to broken or obstructed pipe(s). The VyV= wNtIrerr— Inspection If(with approval of the Board of Health): - broken pipe(s) are'replaced obstruction Is removed revised 9/2/98 Page 2ofII ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:214 Tower Hill Road. 'O s t e r v i l l e ,Mass . owner: Ruth M. Cunnion Dew of 4upectkm: 8/2 4/9 9 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine If the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WiTH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH.YM-L.PRQTECT THE PUBLIC HEALTHAND SAFETY AND THE EWD8OkMENT: Nv Cesspool or privy Is within 60 feet of surface water Cesspool or privy Is within 60 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WiLL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING W A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS Is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS Is within 60 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS Is less than 100 feet but 60 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds Indicates that the well Is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm. Method used to determine distance 41 _(approximation not valid). 3) OTHER The systems rnnG; etg Cif a 6 ' aE8 '' blee4e-- is tank. e . Waste water passes from main cesspool to the overflow cesspool . e,. i revised 9/2/98 Page 3orll t V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 214 Tower Hill Road Osterville ,Mass . Owner: Ruth Cunnion Date of In:pec&-:8/2 4/9 9 D. SYSTEM FAILS: You st Indicate either "Yes" or"No" to each of the following: X I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No , Backup of sewage irrtofeciRtyeraTsrtem component due%to an overloaded orcbgged-SAS•or-ceaspoot. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. r Static liquid level in the distribution box above outlet Invert due to an overloaded or clogged SAS or cesspool. i z Liquid depth in cesspool Is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_a. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. -lC Any portion of a cesspool or privy is-within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for -coliform bacteria, volatile organic-compounds, ammonia nitrogen and nitrate nitrogen. - E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: 'f]� The following criteria apply to large systems In addition to the criteria above: /)U The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No / the system is within 400 feet of a surface drinking water supply the system•is-witWA 200 feetof•o-t+ibutaryAoaeurfaoa•dr+raking•vwter•supPly _ . . .__... .. _ ._ f 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) The owner or operator of any such system shell upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further infor nat)'on. revised 9/2/98 Page 4orn 1 V , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 214 Tower Hill Road Osterville ,Mass . Owner: Ruth M. Cunnion Date of Inspection/2 4/9 9 Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following: Yes No > Pumping information was provided by the owner,occupant,or Board of Health. — -None of the system compossnts.kauajmwn pua pad+foFat-Jeasttwoaweakasadthe-system has Amwni=cainiagwesa W-flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note If they are not available with N/A. — The facility or dwelling was inspected for signs of sewage back-up. / stem The s does not receive non-sanitary or industrial waste flow. Y Y — The site was inspected for signs of breakout. All system components,A luding the Soil Absorption System, have been located on the site. r The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on:- Existing Information. For example, Plan at B.O.H. — Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 115.302(3)(b)) — The facility owner.(and.or—pnats-if differ—from ommar),weraproyidad.with Informatioann tha prnpor rain*a u&aC ^f SubSurface Disposal Systems. i t revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION P,op"Addr"3: 214 Tower Hill Road Osterville ,Mass . Owrw: Muth M. Cunnion Date of Irupection. 8/2 4/9 9 FLOW CONDITIONS RESIDENTIAL: Design flow:NQ_g.p.ddbedro . Number of bedrooms(des'��'-' Number of bedrooms(actual): Total DESIGN flow. Number of current residents- Garbage grinder(yes or no): � Laundry(separate system) a OIQ.— if yes, sepwatelnspection.required --. Laundry system Inspected or no) Seasonal use(yes or no): 4; Water meter readings,If a a labllee'((llast two year's usage(gpd): Sump Pump(yes or no): �AK� f �T r Last date of occupancy: COM M ERCIALAN DUSTRIAL• Type of establishment: Design flow: aaad ( Based on 15.203) Basis of design flow Grease trap present:(yes or no) Industrial Waste Holding Tank present: (yes or no)1efik4 Non sanitary waste discharged to the Title 5 system: ( as or no)— Water meter readings,If avail pble: Last date of occupancy: .11W OTHER:(Describe) .1614 Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of Information: System pumped as part of ins action:(yes or no)AP If yes, volume pumped: gallons Reason for pumping: TYPE F 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installediif known)-and Bourse of Mformation: Sewage odors detected when,arriving at the site:(yes or no)v� f revised 9/2/98 Page 6orii a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:214 Tower Hill Road Osterville ,Mass . Owner: Ruth M. Cunnion Date of Inspectiort: g/2 4/9 9 BUILDING SEWER: (Locate on site plan) Depth below grade: 1) Material of constructio cas on 40 PVC_other(explain) Distance fro tir ate water sup ly well or suction.line Diameter Comments: (condition of Joints, venting,evidence of leakage,-etc.) Joints appear tight No Pvidpnn.p of leakage _ SEPTIC TANK (locate on site plan) Depth below grader Material of construction Alitconcrete4gnsta)O,$Fibergla3vVllgPolyethyleneV 4other(explain) If tank is Fnetal,list age_ Js.age.confirmed by Certificate of Compliance (Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:AX Scum thickness: Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle: W#4 How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or-baffles, depth of liquid level in relation to outlet invert, structuret4ntegrity, evidence of leakage,etc.) Septic tank is not prpspnt . _ GREASE TRAP. $. (locate on site plan) Depth below grade: Material of construction:A�lfconcretevAmeta4LXFiberglass)i�PolyethyleneN40ther(explain) doDimensions Scum thickness: Distance from top of scum to top of outlet tee or baffle& ,'� Distance from bottom of sc,}�m to bottom of outlet tee or baffle% 1 Date of last pumping: Comments: (recommendation for pumping,condition of Inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Grease trap is not present . revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 214 T ov e r Hill Road O s t e r v i l l e ,Mass . Owe: Ruth M. Cunnion Data of trnspeation:8/2 4/9 9 TIGHT OR HOLDING TANK4&f (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade: Material of construction:4)14concrete,f&metaloAFberglass&Polyethylene/&other(explain) Dimensions: Capacity: gallons Design flow: gallonslday Alarm present Alarm level: ff-Alarm in working order:Y934 L,4 Nq&$ Date of previous pumping: 1014 Comments: (condition of inlet tee, condition of alarm and float switches,etc.) Tight or holding tanks are not :scant DISTRIBUTION BOX (locate on site plan) Depth of liquid level above outlet Invert: AM Comments: (note•if level and distribution is equal, evidenoe of solids carryover, evidence of leakage into or out of box, etc.) — -— Distribution box is not present— PUMP CHAMBER:.Lg/ 41f— (locate on site plan) Pumps in working order:(Yes or No) R Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Pump chamber is not present . revised 9/2/98 Page 8orn t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PropertyAddreas214 Tower Hill Road Osterville ,Mass . Owrw: Ruth M. Cunn ' on Dra of inspect;ar,:8/2 4/9 9 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if possible;excavation not required,location may be approximated by non•intrusive methods) If not located, explain: Type: leaching pits, number:, leaching chambers,number: leaching galleries,number: leaching trenches, number, length: leaching fields,number, dimsnslons: overflow cesspool,num er:� Alternative system: 4) Name of Technology: 1 VCO Comments: note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) oamy sand to medium fine sand( No signs of hydraul irz CESSPOOLS: ruIj 6 y (locate on site plan) Number and configuration: Depth-top of liquid to InletPvert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of Inspection) ,Did not pump inflow racgpnol ev®s£lQl� sesepeel }8 dry &Rd Comments: (note condition of soil, signs of hydraulic failure,.level of.ponding,condition of.vegetation, etc.) PRiVY:_ e (locate on site plan) y�,Q Materjals of construe 9n: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.) Privy is not present - revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART C SYSTEM WFOR1.tATION(continued) ProptyAddtou:214 Tower Hill Road Osterville ,Mass . Owe,..: Ruth M. Cunni,on Dau or kwPoc:ion: 8/2 4/9 9 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include des to►t Ie►st two permanent re(erance landmarks or benchmarks locate ►II welts wltNn 100' (Locate where public w►tsr supply comes Into house) ,-:-- —-- �bt 0 z \� O b' I revised 9/2/98 Pap 10of11 f i S# SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropwyAddrass: 214 Tower Hill Road Osterville ,Mass . owner: Ruth M Cunnion Dau of Inspectlon: 8/2 4/9 9 NRCS Report name Soll Type_ Typical depth to groundwater USGS Date website visited Obsorvation Wells checked Groundwater depth: Shallow Modorats Deep _ SITE EXAM Slope Surface water Check Collar Shallow wells i Estimated Depth to Groundwater Feet Please Indicate all the methods used to determine High Groundwater Elevation: _Obtained from Design Plans on record k-/ bservad.Site(Abutting property, bservatlon hole, basement sump etc.) Determined from local conditions Checked with local Board of health _Checked FEMA Maps Checked pumping records hocked local excavators, Installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Used water contours Map . Gahrety & Miller Model 12/16/94 revised 9/2/98 Page 11 of 11 e•rmnrn.-n rr�r•-'t�srnrmnnn+r+s••+.n++rr+s*an:r•►�rn�+�rs+•n.n ne+•ni++sr�raysrs+ .. •�l •rn-rs-r-.ve-n--:•.t,.r••� TOWN OF Barn stable BOARD OF HEALTH 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION II •••rn�►••.-:: -r..tr.^.rrr+rnr.+n•rt.•.u.rvRnrsran-ren-rrt•n-tur+ert�'•v+R�rsi► r�nfn _ :.�rrr•r.-�:•-..1 -TYPE OR PRINT CI.EARL1•- PROPERTY INSPECTED STREET ADDRESS 214 Tower Hill Road Osterville ,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Ruth M. Q0inion PART D - CERTIFICATION NAME OF INSPECTOR _Joseph P.Macomber Jr . COMPANY NAME J. P.Macomber & Serf 'Inc . COMPANY ADDRESS Box •66 Centerville ,Mass. 02632. Street Town or City State LIP COMPANY TELEPHONE ( 5081 775 - 3338 FAX (508 ) 790-1-578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate, and omplete as of the time of .inspection - The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: Systeui PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 . 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED$ The inspection which I have con acted has found that the system fails to Protect the jiublic health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE C11ITERIA of this inspection form . I/A/V Inspector Signature + Date ne copy of this tification must be provided to the OWNER, the BUYER ( where applicable) and the BOARD OF HEAL7'11* * If the inspection FAILED, the owner or.",operator shall u d within one year of the date of the inspection, unless allowed ortrequiredm otherwise as provided in 3.10 CMR 16 . 306 . partd .doc REVISIONS: 28 LOCUS INFORMATION No. DATE DESC. CURRENT OWNER: JAMES & MARY GALLAGHER OVERLAY DISTRICT: WP — N N TITLE REFERENCE: DEED BOOK 24237, PAGE 67 NITROGEN SENSITIVE — c) BUMPS RIVER R ZONE: ZONE II Z d PLAN REFERENCE: PLAN BOOK 206, PAGE 31, F-2 FEMA FLOOD " " — .{ ZONE DISTRICT: C , DATED 7/2/1992 N9 S\' LOCUS r ASSESSORS MAP: 142 PANEL #250001 0016D — p QO PARCEL: 012 v ? r MINIMUM LOT SIZE: 87,120 S.F. — d v ZONING DISTRICT. RC EXISTING LOT SIZE: 17,000f S,F, Cy SETBACKS: FRONT 20' SIDE 10' EXISTING LOT COVERAGE: 1,598t S.F. (9.4%) . MAIN STREET REAR 10' PROPOSED LOT COVERAGE: 1,858f S.F. (10.9%) LOCUS MAP I CERTIFY TO THE BEST OF MY NOT TO SCALE PROFESSIONAL KNOWLEDGE, INFORMATION AND BELIEF THAT THE LOT CORNERS, DIMENSIONS AND SETBACKS TO THE STRUCTURE AS DETERMINED BY INSTRUMENT SURVEY AND AS SHOWN ON THIS PLAN ARE CORRECT. CPAGA iFFW) No.880'�N U0 PROF SIONAL LAND SURVEYOR DATE p�N A1gjge� N CERTIFIED PLOT PLAN � WITH 9.48' PROPOSED � �$.°° BARNSTABLE ADDITION ROAD BOUND FOUND & HELD ` AT N oar #214 O � `��00 � TOWER HILL ROAD P4/A IN Pot OSTERVI LLE SEPnc CJ MANHOLE �,AS �, MAS SAC H U S ETTS Cb (BARNSTABLE COUNTY) 14 0 EXiS214 T1NG �� / UTILITY` g � / # "� / DWELLING � �.. POE O / / BARNSTABLE MARCH 15, 2010 ROA GARAGE FOUND DS&UND HELD .. l OHW OHW OHW OHW _ 11 ITY POLE I / PROPOSED / `,,,ADDInON BARNSTABLE ' 0 *AD IFOUN BOUND D & HELD m M ' / T�� I nz I / L_BUILQjNQ-S-LTBACK _LINE ' I Z r NE _ _ — — I MS ' PREPARED FOR: z Mr. JAMES GALLAGHER c IRON PIPE — — — — — — _ _ _ _ I ZO.o' °Ds im 5 DELWOOD ROAD FOUND 1 FOOT OFF — — _ �i �, 'ca INTO ROAD LAYOUT S8336-00"E CHELMSFORD, MA 01824 y ' o � 188.12' o 1 -978-256-7468 I O 'L ASSESSORS MAP ROAD 2 BSC J�IU r PARCEL 13 J ROBERT POWERS 0 349 Route 28,Unit D I West Yarmouth, Massachusetts 3 02673 508 778 8919 5 I © 2010 The BSC Group, Inc. v SCALE: 1" = 20' 0 2.5 5 10 mum v n 0 10 20 40 nor PROJ. MGR.: CRAIG FIELD n FIELD: P. HAGIST CALC./DESIGN: K. HEALY DRAWN: P. HAGIST is CHECK: CRAIG FIELD FILE: 9489-EXC DWG. NO: 5992-01 SHEET 1 OF 1 JOB. NO: 4=9489.00 i 22'1" ------ ----fi------------- ------- =_- Existing Floor Plan _ f Scale 1/8" = V c - N Cd j GARAGE i� ib• si ii w 21'+l"x 15'-7" I E. 3ase I occ CL .� FAMILY m 13•-6..x 9'.7" `a — 17.4�ia, 40fie 3030 2430 m O • j N LAUNDRY I d KITCHEN 5'•1 x s'-r' 2t 11"x1r-0" W 3'-21 N MASTER BA H LIVING 6•-t,.x r-6.41 C 22 131.1 x 25'.9" G _ � MASTER BDRM DN t C4 fl 2 1 — 0 x Al 10 C r C a ENTRY C C R di E 2eW p ----- — t O = AGO. .—3'-6"—a{�-2-6"42'S 5/8' —T-8 lie'-- 2'-01144.2'-6'-.1--4'-V----�7 6�4.-3'A"- y _ w r 2 V ,p 0 2 H `o C —._—. - 43'a'---- ----- - - c c a IL ti o _= Ew E� BATH /�w��+ 8'-0"x 6'.3" W 10 v 12HALL 7y 31x12.2 rl/ — — BEDROOM— — BEDROOM /_ O tr-o••xte'-tt'• t0'-0"x18•40'•UL cc v 'a 3 f 3/ct �, • cc _ 2 Lm U) 0 .a' E � U er 0 ' d iti n o t° Proposed 12 x 22 Ad o 0 o FAMILY I � 13'-9" x 9'-7" I N Exterior wall U I 26-71' 6-4 7/8" --- 12'-0 3/4" - -- New Bulkhead Access 0 m LAUNDRY 9BIICO Type C Existing Interior Wall -- -- - -- --- _/ 11'-3"x 5'-6" - Lr) o . o u KITCHEN ENTRY -- N M 0o 6'-4" x 10'-7" Fa Foi Qi 21'-11" x 12'-2" ! New Exterior Wall o CO)L -- MASTER BATH N 11'-3" x 8'-2" -1 Cco C C a+" 21'-10 3/4" - —3'-6" — P N New Interior Wall c u �o a� c L' — d R C .p i I Remove Existing Wall C a t �, o d II II - - - - - - - - - - - - - - - - - t 'omC = � e- C� _ ffi '�_- : _� - ----___- CLOSET - - - - - - - - - - - - - - - - - � � ` a � I i $ oCa11'-3" x 6'-6" o W MASTER BDRM w « a 11'-8" x 13'-2" I I I _ _ - - - E it II I � I -UP old co I I II I � Remove stairs infill floor •_ II _ to C� o cc _ E � 0 i Framing Cross Section ti O N N V 6 ■� e venting CD g 4 O .�.+ Match shingle style on roof > a d 2x10kd ridge board 0 m V. 2x8kd rafters 16" o.c. 1/2 plywood sheathing 1Sib felt paper Builder to Adjust Wall Heigth Ice &water Shield eaves & Or Frame Ceiling Joists Same as - cheeks existing House N 1x8 spruce collar ties 48" o.c. To Match Headers and Existing Ceiling joists to be determined 7ifings. c5 2x6 thru 2x10 R-30 fiberglass insulation. o 1/2" blu-board with plaster skim coat. C o Match existing siding , Y Lft 1 Sib felt paper or other house wrap { * N c 1/2" plywood sheathing a , H N c 1° 2x4kd walls 16 o.c. Co C T- a R-13 Fiberglass insulation 0O 0D c t0 1/2" Blu-board with skim coat plaster d V O IM trl C v a Y 2Ow °rOO GRADE O. C) O E u'� y Cut new 4'wide opening .t. ta � N 0Wo Cd Er N ' NO - Proposed Foundation Floor Framing Layout o E 0 N N C 14'-6" - - — —77 _ G _ _ _ _ _ i I I ev vs c y � I I — - I l t � CL CL m U to O 2x10 joists 16"OC C N 11 11 N � 6_0 -- INstall 2x10 Simpson joist I - tV d hangers to ledger. I I - —_-- I I d Attache ledger to existing box I I CCjoists with lag bolts. — �- ----- 12'-1 13/16" M I I N d ------ -- 12'-1 13/16" --- NWAW. c N eC-4 c '0 77 I I I I — � 2 m — — — — — — — — C r to - - - - s — — -- ( - - r- - 1 — 11f 'O pip = to _ - - - — — — — — — — — — — — — — — I I I06 I I av o5 Ent — — — 6-6" 12'-1 13/16" 6'_6" - 12'-113/16" -- - Match Elating Full Wall Height I'• W GRADE 2"X 6"TREATED SILL i PLATE CO SILL SEAL A 1/2"ANCHOR BOLTS 6'O.C. LO 8"POURED CONCRETE N W!VERTICAL REINF(IF REQUIRED) 0 DAMP PROOFING(TO GRADE) _ sl ■ 4"CONCRETE FLOOR `— W/WIRE MESH OPTIONAL 8"X 16"CONT.CONCRETE FOOTING ■T RE-BAR(2) cci P �12"GRAVEL FILL o ._ VAPOR BARRIER 4"GRAVEL w� O BASE W r FOUNDATION -POURED CONCRETE 8"X 8' E d. FOP 08 08 00 -� C4 0 r. gig ' ■ram rrrr m■■■�rrrrw■rm.wwi■wrrwrr■��irr.� ���r■wr•wrw:www■w�rw �' i. ,���..,p .' Ijl� • + ■rr ��`wrrr�i.�rrrr■■.i-wr�.rrri�.wrrwr �Iwrrrrrw�r� �'�� 1�:""'� A .� I j� �w�w mr .r•w�rrrrr•w�rrrri`wIm■wrwriiwwwrrwri.r■w■mwrmrii. 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