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HomeMy WebLinkAbout0088 WATERFIELD ROAD - Health 80 Waterfield RfM> Osterville A= 119 025 a TOWN OF BARNSTABLE C LOCATION �� t' l °`' l SEWAGE # 100 1 VILLAGE- �7`�Q ��� l vu ASSESSOR'S MAP & LOT A INSTALLER'S NAME&PHONE N0. W 11J* .5 J601 RIA 6 SEPTIC TANK CAPACITY 15 o0 LEACIENG FACILITY: (type) r (size) 330 X Z66 Y- NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: 7 COMPL ANCE DATE: lU 1 I l I n 1 Separation Distance Between the: a' Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private.Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 35 71 Fee 1 No. ; THE COMMONWEALTH OF MASSACHaETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Diopozaf *rwm Cow5truction 3pernait Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System ElIndividual Components Location Address or Lot No. Owner's N e,Address and Tel.No. 5 +t 'ISD&&V�3R&� ^C $ Assessor's Map/Parcel j /Q/ © � /J,Q. i/SMAIA Ij ^(1 b am , ss an M. /T(el.No. De ne's am ,Address Tel.M. Ito Ike L� ' Type of Building: j d Dwelling No.of Bedrooms J — Lot Size sq.ft. Garbage Grinder( ) �! C Other Type of Building 1q,01M G No.of Persons IT Showers(/) Cafeteria( ) 3 Other Fixtures oeae1460 swY, 70,64?T o AJ 5JWG_X l� Design Flow Jo gallons per day. Calculated daily flow �� gallons. Plan Date Yll'blPt Number of sheets f Revision Date (o 4Q Title T Size of Septic Tank I M 00 61K—. Type of S.A.S. C `� Description of Soil Q.,6 " L'6/'�,/�017 f/ J191VIO es _ x (uy,2 /1 7-2- > 5 ft/b Nature of Repairs or Alterations(Answer when applicable) N MAJ Date last inspected: Agree nt: e undersigned agrees'o ensure the construction and maintenance of the afore described on-site sewage disposal system in ccordance with the provisions of Title 5 of the nviro mental C and�noace the system in operation until Certifi- ate of Compliance has been is is of H, th. • Signed t� Date ell,�/_O/ Application Approved by Date Application Disapproved for the following reasons • ��, Permit No. �:)C�D\— (0 1 ' Date Issued 0 1 _ . 9 No. Fee -� `- Entered in computer:✓ THE'}COMMONWEALTH OF MASSAC_Rl TTS Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS 2p phratton for �Nopogal *pgtem Congtruction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) Complete,System O`Individual Components ..�� Location Address or Lot No. \ Owner's N e,Address and Tel.No. Ts g Assessor's Map/Parcel / /Q/ou �L 4 r. #; D/ .d�i/l'IX SI-tej yowl nb Nam , ss and Tel No. Design's 14ame,Address d Tel.,No nType of Building: s o Dwelling No of Bedrooms Let Size M 4/ sq.ft. Garbage Grinder( ) C Other Type of Building No.of Persons 3 Showers(/) Cafeteria( ) Other Fixtures k/7e_14UAJ sw K, 7 o144yT ., 6 t"y 5/kxJ G�/i¢56/Cs� Design Flow 3o.- t . gallons per day. Calculated daily flow - �. allons. Plan Date I b �. Number of sheets Revision Date" 'Title 11 S 5T /74 _ Size of Tank Q Type of S.A.S. '" — �1 c / `� 'Description of Soil; D �/ ����� Sr�ri,� �( .�.�"JJ- �' ZCs:�1'��{`.� �)'x Lyy L may,, Nature of Repairs or Alterations Answer when applicable) G y� ✓ 7�7(i✓/ '' ' � . P ( PP � ) Date-last inspected: U/V P A reeTent: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system 1 ccordance with the provisions-of Title 5 of the nviro�tmental C` and not o place the system in operation until Certifi- �ate of Compliance has been issu this B of H lth. 1 Signed p, Date � l Application Approved by Ls •�' ic_ Q Date Application Disapproved for the following reasons d Permit No - l0 1 15� Date Issued 911 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 has been constructed in a cordance .with the provisions of Title 5 and the for Disposal System,Construction Permit No.,'b ! (n _dated cT Installer Designer _ 3 The issuance of tPis permit shall not be construed as a guarantee that the system will Unction as esig ed. Date ��1� 2 o 1 Inspector ;ol. t 1 Ulu No. 9�'� �f>� b Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 30tgpogal *pgtem Congtructton Permit Permission is hereby granted to Construct(X,)Repair( )Upgrade( 1 Abandon( ) 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 Permit.-• Date: 9 Approved by ��� ��.- 5 ti .; gh -. a -}fir 7R.3 318.ahv e. n7 Hf.•r _1rv °u`�3r-i �"v' �¢ .`�-�' hyd +yam' t Pfit u,�"-a. 1s`1.P .. J"�� ' -q, O TOWN F BARNSTABLE .. ,k LOCATION $IS 1,y 144,e r -i-j L Id SEWAGE.# �. va..LAGE S�P� r i I C� ASSESSOR'S MAP,'&LOT INSTALLER'S NAME&PHONE NO. � SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (Size) 3b X ZU6,-Ya NO.OF BEDROOMS 2` xlc�X a' w1S BUILDER OR OWNER PERMITDATE: `1 COMPLIANCE DATE: �1J I °I O 1 Separation Distance Between the: Maximum Adjusted Groundwater Table'.to the Bottom of Leaching Facility Feet: Private Water Supply Well and Leaching FaciLt tlf:any wells east on site or within 200 feet of leaching facility) Feet ;; Edge of Wetland and;Leaching-Facility(If any wetlands exist wittun 300:'feef of leaching facility) Feer Furhished by. ZA iL j . .. ...:: . .... g i yOd3O4 P _ 02 s Town of BarnstableBarnstableuts Department of Health,Safety, and Environmental Services Public Health Division •'. Si Date •aA1t J67 Main Street,llyannis MA 02601 mwaa LARM I.[q p. FontKt" Date Scheduled 1 ` Time ��V Fee Pd. oil Suitability Assesstnent for .Sewage Disposal Performed By: Q (AA r 5 A Gbt-/ Witnessed Fay: : a-CA ,'T1ON. c GENERAL: FORMATION. L ocationss O� D OAb O er's Name SuL`V�p� /QA,r}`�� (-� VVt' t1 Addre s r t A r Sn r+�� a t; Lo C,u 5 /Parcel: ��� /P 0Z5 Engineer's Name GOAC't"' AL f_Et"&' NEW CONSTRUCTION X` REPAIR r �j Telephone N Go$ Land Use ...._ 1t f �'DFa.I�AI., .Slopes(^/o)-- �OIFJ Er' Stones Distances from: Open Water Body Z C It I•ossiMe Wet Area� _ 1 �� It Drinking Water Well ZOO* n Drainage Way l00't it Property Line eft.._ t/J _R .Other n SKETCH: (Street name,dimensions of lot,exact locations of lest holes&Pere tests,locate wetlands in proximity to holes) 201 �12oI �o�k1'1 ED L4] Parent material(geologic) l' Depth to Bedrock 3Q Depth to Groundwater: Standing Water in Hole: �o�E Weeping from Pit Face Estimated Seasonal High Groundwater �0 DETE�NATIONI+OR=SEASONAL HYGH WATER:TABLE Method Used: 1.1 . . .,..... Depth Observed standing in obs.hole: in. Depth to soil tnottles: Depth to weeping from side ofobs.Role: in. Index Well t7 Rradina Date: Index Well level °t. Groundwater Adjustment n " ------ ._.—_ Arl,i.factor_._ Adj.Groundwater Level PERC(�LATTOF�I TEST tl - ! Time C Observation I Hole a Time at 9" Depth oC Perc • ^ Time at 6" _ Start Pre-soak Time C V :t7 0 Time(9"�") Find Pre-soak Rate Min./Inch ZJ Site Suitahility Assessment: Site Paused Site Failed: Additional Testing Needed(Y/N) Original: Pllhlic health Division Observation Hole Data To Be Completed on Back---•--j Copy: Applicant Aug-04-00 12 = 40 BARNSTABLE HEALTH OEPT 5087906304 P _ 03 DEEP::0131EY2!VATI.OtV' IOZ,E ;OC:, Yole:# Depth fmm Soii Floriznn Soil Texture Snrl Color Soil Other Surface (USDA) (Munsell) Mottling (Structure,Stones, Unulderes. Y - enev.% �ravcll oAmI Qi.tt> p lZo� v&0 (YtVlJrrl, AraO SG DEEP:OBSERVATION:HOLE LOG Depth from Soil Horizon SoH Texture Soil Color Soil Othcr Surface(in.) (USDA) (Munsell) Mottling (S(nreture,Stones,13oulderes. m e -Z5 vel loam-'-y G 116 A W 0 SL r. DEEP OBSERVATION.1101,E L OG Dole# Depth(ram Soil Horizon Soil Texurrc Soil Color Soil Olhcr Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones, r3ouidcres. nsisterlcv % Gravel) DEEP OBSERVATION HOLE.LO.G Hole# Depth from Soil I lorizon Soil Texture Soil Color Soil 011rcr Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Bouldcres. (Uistcncv."/a Gravel) I Flood Insurance Kate Man: �/ Above 500 year flood boundary No- Yes Within 500 year boundary No Yes Within 100 year hood boundnry No Yes e tlt of Naturally Occurring Pervious Material Dues at least four feet of naturally occurring pervio s material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious tnaterial? Certification q I certify that on _'� ( (date) i ve passed the soil evaluator examination approved by the Department of •nvironm ntal Prote on nd hat the above analysis was perfor ed b me consistent with the required tni expe 'so an pe c e described in 310 CMR. 15.017. Signature Date lJ Q ' a. LOCUS .DEEP 013SER VA TION HOLE LOGS NO SCALE PLAN RE FERENC ESTIMATED HIGH CALCULATION (USGS/ccC METdOD) N /A DEEP OBSERVATION HOLE 1 EL 99.1 PLAN BOOK: 78 PAGE. 109 to DATE OF TESTS: AUGUST 9, 2001 INDEX WELL ZONE DATE: APRIL 15, 1947 DEPTH FROM SOIL SOIL SOIL COLOR SOIL PERCOLATION RATE : LESS THAN 2 MINUTES PER INCH DROP SURFACE HOR Z TEXTURE OTHER g (MUNSELL) MoTTIjNr. :, s; -IN THE C HORIZON IN DOH #1 DATE OF READING: DEPTH TO GROUNDWATER: ASSESSOR'S MAP 119 PARCEL 21; ON 6" A LOAMY SAND 10 YR 3/2 NONE HTNESSED BY JOHN G. SCHNAIBLE, CEC GROUNDWATER lVEL ADJUSTMENT- GLENN HARRINGTON, HEALTH AGENT 6' - 32* 8 LOAMY SAND 10 YR 5/6 NONE NO GROUNDWATER ENCOUNTERED ACTUAL GROUNDWATER LEVEL 0 SITE: EL= 32" 120* C SAND 10 YR 7/4 NONE LOOSE, MEDIUM ES11MATED (MAX.) HIGH GROUNDWATER LEVEL EL= SAND tp PERC AT 61r NO GROUNDWATER ENCOUNTERED OVERMLLIEV MASSr, DEEP OBSERVATION HOLE 2 EL = 99.6 KEY.' MAP NO SCALE, DEPTH FROM SOIL SOIL SOIL COLOR SOIL SURFACE HORIZON TEXTURE (MUNSELL) MOTTLING OTHER ON - 5" A LOAMY SAND 10 YR 3/2 NONE 5m - 25* 8 LOAMY SAND 10 YR 5/6 NONE 25" 125* C SAND 10 YR 7/4 NONE LOOSE, MEDIUM ASSESSOR'S MAP 119 SAND PARCEL 15 LOT 4 NO GROUNDWATER ENCOUNTERED DESI GN CALCULA TIONS LEGEND GV DESIGN FLOW: 3 BEDROOMS AT 11660 AY8500 D F ppgtME141 POLE BENCHMARK:EDGE #3Q1IS 77NG TOP OF CONCRETE BOUND EX 330 GPD X 200%- GALLONS AY USE GALLON SEPTIC TANK, MIN. ALLOWED A 29.5 'L x 10 'W. x 2 'D. LEACHING CHAMBER CAN LEACH: MINE 4ii ELEV.= 102.2 (ASSUMED) 0 CATCH BASIN Vt 29.5 2 ) 2 1 x .74 + 129.5 ( 10 x .74 + 110 ( 2 ) 2 x .74 = 335.2 GPD G CESSPOOL ov INSTALL ONE 1 29.5 'L. x 10 V. x 2 'D. LEACHING CHAMBER Vt 335.2 GPD > 330 GPD REQ'D. ONE 1 w ASSESSOR'S MAP 119 M GAS VALVE 1500 GAL SEPTIC TANK, MINIMUM ALLOWED PARCEL24 ONE 1 DISTRIBUTION BOX 5 OUTLET) w wv wv LOT 13 WATER VALVE -.4 S) # q, UTILITY POLE o y' Y�i ILI NO TES OHW— OVERHEAD U11UTY LINE 1) GARBAGE GRINDERS ARE NOT ALLOWED WITH THIS DESIGN. 4�i A :4, ­1 . ASSESSOR'S MAP 119 2) THE INSTALLER IS RESPONSIBLE FOR ASSURING THAT COMPONENTS OF -)Do CONCRETE BOUND PARCEL 52 PROPOSED THE SEWAGE DISPOSAL SYSTEM ARE DESIGNED WITH SUFFICIENT 4Xw —1500 GALLON STRENGTH TO SUSTAIN ALL LOADS TO BE IMPOSED ON M. LOT J ANY 'k ANK G GAS MAIN SEP77C T COMPONENT OF THE SYSTEM SUBJECT TO VEHICULAR TRAFFIC MUST PROPOSED -goo_ _ COMPLY WITH A MINIMUM STANDARD OF A.A.S.H.T.O. H-20 WHEEL LOADS. WATER SERVICE —W WATER LINE 3) PRIOR TO SETTING MY SEWAGE DISPOSAL SYSTEM COMPONENT, INSTALLER DOH #2 - -loo- - CONTOUR AND REPORT ANY DISCREPANCIES TO THE DESIGN ENGINEER. SHALL VERIFY EXISTING CONDITIONS, INCLUDING ELEVATIONS OF EXIT INVERTS, C5 4 ALL GRAVITY SEWER PIPE SHALL BE 4' DIA. SCH 40 PVC UNLESS OTHERWISE STOCKADE FENCE EXISTING NOTED. THE MINIMUM SLOPE OF 4� DIA. SCH 40 PVC SHALL BE 0.01 FT/FT. WATER SERVICE D-BOX X 5) NO PART OF fHIS DESIGN SHALL BE ALTERED WITHOUT PRIOR APPROVAL STONE-WALL RMVE FROM THE DESIGN ENGINEER AND THE AGENT OF THE LOCAL BOARD OF HEALTH. ALL REQUESTS FOR CHANGES SHALL BE MADE IN WRITING PRIOR ARFA TO CONSTRUCTION. iRT EXISTING C', 10 PROPOSED CONTOUR 6) THE USE OF ALTERNATE MANUFACTURERS FOR SYSTEM COMPONENTS SHALL NOT BE APPROVED IF THE USE OF THEIR EQUIPMENT REQUIRES IN— WATER LINE CHANGES IN DESIGN. c -PROPOSED 7) THE INSTALLER SHALL ASCERTAIN THE LOCATION OF EXISTING UNDERGROUND 9.5L x 10 V. x 2`D. UTILITIES PRIOR TO EXCAVATION AND SHALL PROTECT UTILITIES WITHIN THE WORK AREA DURING CONSTRUCTION. ov ASSESSOR'S MAP 119 LEACHING,CHAMBER PARCEL 26 EXISTING CESSPOOL n1f 8) THE EXISTING SEWAGE DISPOSAL SYSTEM (INCLUDING CESSPOOLS) SHALL BE LOT 15 PUMPED, FILLED WITH SAND, AND ABANDONED; OR SHALL BE REMOVED (SEE NOTE 81- 10# HEIRS OF ESTATE OF WITH SURROUNDING CONTAMINATED SOILS AND BACKFILLED WITH CLEAN GARFIELD CROCKER COARSE SAND. LOT 14 ASSESSOR'S MAP 119 PARCEL, 25 AREA 16,446 S.F. INSPECTION NOTE ONE (l)- 29'-6"L x 10'W x 2'D LEACHING CHAMBER CONSTRUCT PLAN BY PLACING THREE 8'-6* x 4'-10* x 3'-0* LEACHING CHAMBER THE STATE ENVIRONMENTAL CODE, TITLE, 5, REQUIRES INSPECTION(S) UNITS END TO END WITH 2'-0m STONE ON ENDS AND 2'-7- SCALE: 1*= 20' OF THE SEWAGE DISPOSAL SYSTEM BY THEVESIGN ENGINEER. STONE ON SIDES. (USE 500 GALLON LEACH CHAMBER UNITS AS THIS AREA IS SERVED BY TOWN WATER) INSTALLATION CONTRACTOR MUST NOTIFY THE.QESIGN ENGINEER TOP OF FOUNDATION MANUFACTURED BY SHOREY PRECAST OR EQUAL). PRIOR TO THE START OF INSTALLATION FOR DISCUSSION ON L. 101.00 1 REQUIRED INSPECTIONS. RAISE COVERS TO WITHIN 6* 160 40 OF FINISH GRADE ........................ FINISH GRADE---,,, (IN FEET) ��f j�'�,�j�/,l�i��,�`;~�,/ V MIN. 'Xv- N OBox s MAX. MINIMUM D80X INSIDE 3. MAX DIMENSIONS 12" x 12 DROP-2* MIN 4' DIA SCH 40 PVC PIPE 3* MAX FLOW LINE 40 Pvc PIPE 2' LAYER OF 1/r 4* DIA SCH 40 PVC PIPE 10 SEE INLET IM- f 01ARAHM ' l TO 1/2- STONE UQW DEPTH KTIM TEE OUTLET PIPE OR FLOW 26-0& D'BOX 15M GAL LEVELER INVERT EFFECTIVE NO. DATE REA" by. SEPTIC TANK DEPTH BOTH 9640 PROJECT NO. W/SANITARY TEES OtEf::)� 3/4' TO 1 1/2 STONE SHEET TITLE ALL C15494.00 COMPACTED BASE W/ 6* CRUSHED STONE THE MINIMUM SLOPE FOR LAYER OF SEWAGEDISPO'Q AL . S YSTEM P LIAN 4* DIA SO4 40 PVC E i 2-7" 4*-10* 2'-7* DATE ALL PIPE IS 1/8* PER FT I- , 1_0 C14 FOR AN NEW RESIDENCE COMPACTED BASE GAS BAFFLE USE o 8/16/01 W/ 6- LAYER OF 'TUF-TITE' OR 10' mo NOTE: PROJECT DRAWN BY END VIEW CRUSHED STONE APPROVED EQUIVALENT LINE(S) E)OTING D-BOX MUST REMAIN ^0 lo 0 MAH/PK LEVEL FOR 2*-0* BEFORE PITCHING 0 0 THE INFORMATION HEREON HAS BEEN PREPARED ACCORDING TO DOWN TO LEACHING FACILITY THE REQUIREMENTS OF TITLE 5 OF THE STATE ENVIRONMENTAL CHECKED fff LIQUID DEPTH Oum im DEPTH Orly 10' MIN ............. BELOW FLOW LINE 10! 12- ESTIMATED DEPTH I CODE FOR SUBSURFACE DISPOSAL OF SANITARY SEWAGE AND MURPHY RESTORATION & REMODELING 1519M I NO. 4 FT 14 INCHES LONGEST RUN TO GROUNDWATER IS > 20 FT '041 LOCAL BOARD OF HEALTH REGULATIONS. � ew 80 WATERFIELD ROAD OSTERVILLE MA Cl 5494.dwg 5 FT 19 INCHES 29'-6" 6 " 24 "IS 7 FT 29 INCHES V, COASTAL ENGINEERING 'AW".7, COMPANY, INC. X>04 G, DETAIL OF LEA CHI NG CHAMBERS PROFESSIONAL ENGINEERS & LAND SURVEYORS SS- 11 40. SCHEMA TIC FLOW PROFILE NO SCALE 260 CRANBERRY HIGHWAY sit ORLEANS, MASS. 02653 ALL INSTALLATIONS MUST CONFORM TO THE MINIMUM REQUIREMENTS OF TITLE 5 (508) 255-6511 1 OF ISHEETS BOUND -D) CEC 2001 C15494.00 f , Commonwealth of Massachusetts / AW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M a 88 Waterfield Drive . Property Address William Sullivan, Brett& Kelly Ramsdell, Patricia Carlino, Karen Taverna .Ma Owner Owner's Name information is : required for every Osterville MA 02655 3/28/2018 page. City/Town State Zip Code Date of Inspection rr.3 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information l aq(s I filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not James Ford use the return Name of Inspector key. - 1 Ford.Septic Services, LLC " roa Company Name P.O. Box 49 Company Address ,ef�m Osterville MA 02655 City/Town State Zip Code 508-862-9400 S12482 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 v uation by the Local Approving Authority 3/30/2018 Inspec r Signature Date The s t m inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healt 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. t **"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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 G e)d vs ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 88 Waterfield Drive Property Address William Sullivan, Brett& Kelly Ramsdell, Patricia Carlino, Karen Taverna Owner Owner's Name information is required for every Osterville MA 02655 3/28/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria'described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. ' Comments: 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)- z t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 88 Waterfield Drive Property Address William Sullivan, Brett& Kelly Ramsdell, Patricia Carlino Karen Taverna Owner Owners Name information is required for every Osterville MA 02655 3/28/2018 page. 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): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1.. System will pass unless Board of Health determines.in accordance with 310 CMR -15.303(1)(b)that the system is not functioning in a maner which will protect public health, safety and the environment: r ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a.salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 88 Waterfield Drive Property Address William Sullivan, Brett& Kelly Ramsdell, Patricia Carlino, Karen Taverna Owner Owners Name information is required for every Osterville MA 02655 3/28/2018 page. CitylTown 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 ❑ N . Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of.17 i Commonwealth of Massachusetts _ v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments f 88 Waterfield Drive Property Address William Sullivan, Brett& Kelly Ramsdell, Patricia Carlino Karen Taverna Owner Owners Name information is required for every Osterville MA 02655 3/28/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cost.) 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. _ ❑ Z 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. -- i For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. t - 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 E] 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-3/13 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 �M a 88 Waterfield Drive Property Address William Sullivan, Brett& Kelly Ramsdell Patricia Carlino Karen Taverna Owner Owners Name information is required for every Osterville MA 02655 3/28/2018 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 d ® ❑ 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? El ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow!based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9,•'' 88 Waterfield Drive Property Address William Sullivan, Brett& Kelly Ramsdell, Patricia Carlino Karen Taverna Owner Owners Name information is required for every Osterville MA 02655 3/28/2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: . Design flow(based on 310 CMR 15.203): Gallons per day(qpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ .No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °° ,•y'�• 88 Waterfield Drive A Property Address William Sullivan, Brett& Kelly Ramsdell Patricia Carlino Karen Taverna Owner Owners Name information is required for every OSterville MA 02655 3/28/2018 page. CitylTown 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 5 years ago Was system pumped as part of the inspection? 0 Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Reason for pumping: maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool El Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Waterfield Drive Property Address William Sullivan, Brett& Kelly Ramsdell, Patricia Carlino, Karen Taverna Owner Owners Name information is required for every Osterville MA 02655 3/28/2018 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: system installed - 10/19/2001 per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate.on site plan): Depth below grade: ' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 18" 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: 1500 H-10 Sludge depth: 2 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M e 88 Waterfield Drive Property Address .William_ Sullivan, Brett& Kelly Ramsdell Patricia Carlino Karen Taverna Owner Owners Name information is Osterville required for every MA 02655 3/28/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 13 How were dimensions determined? measure , Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tees were present.The liquid level was even with the outlet invert There was no sign of leakage. Grease Trap (locate on site plan): Depth below grade: n/a feet Material of construction: . ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from;bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Waterfield Drive Property Address William Sullivan, Brett& Kelly Ramsdell Patricia Carlino Karen Taverna Owner Owners Name information is required for every Osterville MA 02655 3/28/2018 page. City/Town State . Zip Code Date of Inspection D. System Information (cont.) Comments (on ipumping 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: e, n/a Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El 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 :sins•3113 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 C"�M a,•' '88 Waterfield Drive Property Address William Sullivan, Brett& Kelly Ramsdell, Patricia Carlino; Karen Taverna Owner Owner's Name information is required for every Osterville MA 02655 3/28/2018 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 even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The D-box was normal. Speed levers were present. Pump Chamber(locate on site plan): Pumps in working order: E. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 112 of 17 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Waterfield Drive Property Address William Sullivan, Brett& Kelly Ramsdell, Patricia Carlino Karen Taverna Owner Owners Name isrequired for every Osteryille MA 02655 3/28/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3-500 gal. chambers ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The chambers were dry and clean.There was no sign of failure. A camera was used for the 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 i Depth of scum layer Dimensions of cesspool y Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts 6A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M a,•'` 88 Waterfield Drive f Property Address William Sullivan, Brett& Kelly Ramsdell Patricia Carlino Karen Taverna Owner Owners Name information is required for every Osterville MA 02655 3/28/2018 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.): N/a t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 s � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,•y'°t 88 Waterfield Drive' Property Address William Sullivan, Brett& Kelly Ramsdell Patricia Carlino Karen Taverna Owner Owners Name information is Osterville required for every MA 02655 3/28/2018 City/Town/Town page. Y 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 aoor a 0 0 0 s y 16 416 a a I 33 yo y� q,5 t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts C u v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a,•''V 88 Waterfield Drive Property Address William Sullivan, Brett& Kelly Ramsdell Patricia Carlino Karen Taverna Owner Owners Name information is Osterville required for every MA 02655 3/28/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope t ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: . Using topo and water contours maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 88 Waterfield Drive Property Address William Sullivan, Brett& Kelly Ramsdell, Patricia Carlino, Karen Taverna Owner Owner's Name information is required for every Osterville MA 02655 3/28/2018 - 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17