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Home My WebLink About0126 WATERFIELD ROAD - Health 126 Waterfield Road Osterville F/R A = 119 021 _ " o ° � a a ° y ° ° ° , a ° a ° ° ^ n w ' a ° x e ° M1 R � c 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 Water-field Rd Property Address Sharon Kennedy Owner Owner's Name information is required for Osterville Ma 02655 4-15-15 every page. City/Town State Zip Code _ Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the '0jq 4, computer, use 1. Inspector: ( only the tab key to move your Brett Hickey cursor-do not Name of Inspector use the return key. B&B Excavation Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 BQ/1 Citylrown State Zip Code (508)477-0653 S113747 Telephone Number License.Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4-15-15 Inspe is 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 z•� has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 e 69 + V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 126 Waterfield Rd Property Address Sharon Kennedy Owner Owner's Name information is required for Osterville Ma 02655 4-15-15 every 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: ® 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 Waterfield Rd Property Address Sharon Kennedy Owner Owner's Name information is required for Osterville Ma 02655 4-15-15 every page. Cityrrown 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): ❑ obstructions is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment.. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Waterfield Rd Property Address Sharon Kennedy Owner Owner's Name information is required for Osteryille Ma 02655 4-15-15 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system'(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to.overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 126 Waterfield Rd Property Address Sharon Kennedy Owner Owner's Name information is Osterville Ma 02655 4-15-15 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or, tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a,private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design,flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 Water-field Rd Property Address Sharon Kennedy Owner Owner's Name information is required for Osteryille Ma 02655 4-15-15 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ E Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were an of the system components pumped out in the previous two weeks? Y Y P P P ❑ ® 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? ® Ej Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with El ® 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: 1.10 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 126 Waterfield Rd Property Address L Sharon Kennedy Owner Owner's Name information is required for Osterville Ma 02655 4-15-15 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage see below 9 ( Y 9 (gPd))� Detail 2013- 11,000 2014-21,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: 2 months prior Date i Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(spd) 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 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 Waterfield Rd Property Address Sharon Kennedy Owner Owner's Name information is required for Osterville Ma 02655 4-15-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 Waterfield Rd Property Address Sharon Kennedy Owner Owner's Name information is.required for Osterville Ma 02655 4-15-151 . every page. Cityrrown State Zip Code Date of Inspection D. System. Information (cont.) Approximate age of a[I components, date installed (if known) and source of information: 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 31" 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.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank(locate on site plan): 19" 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 gallon Sludge depth: 5" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Waterfield Rd Property Address Sharon Kennedy Owner Owner's Name information is Osterville Ma 02655 4-15-15 required,for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 31" I - 0„ Scum thickness Distance from top of scum to top of outlet tee or baffle na Distance from bottom of scum to bottom of outlet tee or baffle na How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order,Tees present no sign of back- up.Liquid level equal with outlet invert. Tank not in need of pumping at this time Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 Waterfield Rd Property Address Sharon Kennedy Owner Owner's Name information is required for Osterville Ma 02655 4-15-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 111 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Foram Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Waterfield Rd Property Address Sharon Kennedy Owner Owner's Name information is required for Osterville Ma 02655 4-15-15 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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.): At time of inspection d-box appears to be in working order no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * 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 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Waterfield Rd Property Address Sharon Kennedy Owner Owner's Name information is required for Osterville Ma 02655 4-15-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gallon ❑ 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Chambers were dry at time of inspection. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool. . Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/n Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Waterfield Rd Property Address Sharon Kennedy Owner. Owner's Name information is Osteryille Ma 02655 4-15-15 required for every page. City/Town State Zip Code. Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 126 Waterfield Rd Property Address Sharon Kennedy Owner. Owner's Name information is required for Osterville Ma 02655 4-15-15 every page. Cityrrown 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 �eac- � Q tl A 3 �T ntfCec�4 ` l: ' 21 Tank 0,jlee Che.,,he 0o 33.' t5ins•3/1.3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 N Commonwealth of Massachusetts Title 5 official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 126 Waterfield Rd Property Address Sharon Kennedy Owner Owner's Name information is required for Osterville Ma 02655 4-15-15 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No Gw 144" 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: 8-12-02Date ❑ 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: Plan on file at BOH 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 126 Waterfield Rd Property Address Sharon Kennedy Owner Owner's Name information is required for Osteryille Ma 02655 4-15-15 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® inspection Summary D (System Failure Criteria Applicable to All Systems) completed Z System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file 0 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 C c>ti Town' Of Barnstable Office: 508-862-4644 may. Fax: 508-790-6304 Regulatory Services Department * enrnaa Public Health Division Mom` Thomas A.McKean,CHO 019, 200 Main Street, Hyannis, MA 02601 Payment Receipt 4 a Septic Inspection Payment received 25.00 (Check) on4127/2015 Permit number: 10796 Check number: 1956 Check amount: 25.00 Name on-check: B&B Excavation u ,. ;Owner: SHARON M TR KENNEDY ;Address: 126 WATERFIELD ROAD,Osterville y t p - TOWN OF BARNSTABLE LOtC,ATION W<fei'-(�'Ad R!/� SEWAGE # 200A 3�y VILLA�>E 06ree- de ASSESSOR'S MAP & LOT ,p 4 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 0- 5700� � mlxo-s (size) NO. OF BEDROOMS 3 BUILDER OR OWNER vc r PERMITDATE: OZ COMPLIANCE DATE: ` D1 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet e i-Pri3ate 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 Y I `y /3 / �Ga✓1/� GPn fPs� 33 i 37' a�1` o � 3 jf No. `% ! FEE COMMONWEALTH ® MASSACHUSETTS r ✓ Board of Health, &!-rMA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(/upgrade( ) Abandon( ) - ❑Complete System El Individual Components Location 121p A-T�.•t�-tt� Owner's Name .71Cq X VIACk -7 Map/Parcel# Address /2 Za/tl/!c (.,e Lot# ® Telephone# Soli-- yZo-- - 25 G Installer's Name ! Designer's Name STD Address 0 Joe o¢ Address 42 Canterbury Lane 4 .,►�lj"!/ti .C. !/�iils7�sus �� JRant Falmouth, MA 02536 Telephone# S-OS— VZ"_ 0/5 Is- Telephone# Telephone: 508/540-2534 Type of Building Lot Size 1 sq.ft. f ling of Bedrooms Garage grinderof Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow(min.required) 75750 gpd Calculated design flow 3 3 Design flow provided gpd Plan: Date L Number of sheets % Revision Date Title io •• Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator S• is Date of Evaluation ,,tr.�s t Iv: L't DESCRIPTION OF REPAIRS OR ALTERATIONS The undersi d agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agVs o n to place a sys in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspection _ l/ ,► No. _ ~• �i FEE - .�... c 4 .fie' / , • —_ { 4 COMMONWEALTH ®I;'MAS-SACHUSETTS =-- - Board of Health, AMA. ' y APPLICATION F® =-$YSTEM CONSTRUCTION PERMIT (Application for a Permit to Construct RepairAbandon( - ❑Complete System ❑Individual Components Location Z A,t �K Owner's Name 7 r g v c/C f - Map/Parcel# q 1.Z Address 'Z r�u X /4 �' t Lot# Telephone# €.Sd�r ��v S Installer's Name C /f0 Designer's Name STEPHEN J. Y Address U Address E Canterbury Lane Telephone# 50s- yzs- C>5 51- Telephone# Telephone: 508/540-2534 Type of Building Lot Size welling to.of Bedrooms 3 Garbage grinder O Type of Building No.of persons Showers ( ),Cafeteria( ) Other Fixtures Design Flow(ruin. required) 103 D gpd Calculated design flow -3 3 Design flow provided 3A 1b gpd Plan: Date A,. L.U%f % Number of sheets evis-on Date Title '�cUl� • ��r-1 • UG/l�A.�tZ ��A�..�+ "�C�M 1'Z.�®, ��-1�'"�'1�,'C��t'�, �.� Description of Soil(s) tL �� ,h S'+ Z-b Soil Evaluator Form No. Name of Soil Evaluator 5• � b & Date of Evaluation Z V. D� t DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr r o not to place the sys in operation until a Certificate of Compliance has been issued by the Board of Health. Signed ( Date y— p 2-- / n. a Inspection 2Y ( '� 9t/ I Ll' D V No. 351COMMONWEALTH FEE OF MASSAC14USETTS Board of Health, 8*�A S_�L 6 LQ , MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) ' Complete System The undersigned hereby fy that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( ) _ by: . at lNc.�P� c d n, ✓ �.: has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated Approved Design Flow (gpd) Installer n , 10 . Designer: Inspector: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. r• No. 95/1 FEE COMMONWEALTH OF MASSACHUSLTTS Board of Health, Vrt,4a �(e- -, AM. DISPOSAL SYSTEM CONSTRUCTION PERMIT Perm' ion is hereby granted to; Construct( ) Repair( Upgrade( bandgn(, ) an individual sewage disposal system at W 1 V as described in the application for Disposal System Construction Permit No. ,dated Provided: Construction shall be completed within three years of the date of this it. 1 ditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date 9-/9- OZ Board of Health i TOWN OF BARNSTABLE LOCATION We,te SEWA GE # --?O®02 - 3 S VILLAGE DS�� (�� ASSESSOR'S MAP & LOT -D INSTALLER'S NAME&PHONE NO. J C. Ars /15 om► S7�'vc 7e.'v SEPTIC TANK CAPACITY �S~�®g T•-+�C r - LEACHING FACII.ITY: (type) (size) /3'k a75 L k o? %� NO.OF BEDROOMS 3 e BUILDER OR OWNER c r PERMITDATE: /A— oZ COMPLIANCE DATE: lIl Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet -.Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by RCfA Cor�;pr5 Afi A /3 Act a7. 33 T� ��/Pf 31' a�1 o � �V_ �7-/fog( �� L �� 13' i j i I 1 L O CAT ION i SEWAGE PERMIT NO. gcl VILl CE COS � INSTALLER'S NAME i ADDRESS ' .f.,.. BUILDER OR GINNER s GATE PERMIT ISSUED 13 DAT E COMPLIA,NCE ISSUED0� �� 3 is � k w 1 eke e4 �t L ui �. No...8... � Fmc..$...10.00........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH T own Barnstable .....................OF............................_............._.....-------•----------...............--------- Allpfira taau for Uisp ial Works Cnowi rurtuaan Prruttt Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: 126 WAtexf�.e1d..8d..,...0.ater'�a_11e.,_.11A__...Q2b55.... _..-•-•---........................................................................................ • Location-Address or Lot No. Mich Qj..,5n1'SlQx................... ............... ................................................. 12&.Waterfie1d..Bd-a.....Dgtarville.,-_ZA....A265-5 Owner Address A &.-B__CessPoo�-_S xY�.ce_________________________________________________ 12B..Bi_skips_.Te=a.Qe....Uaaanis,._S4A__...026B.1........ Installer Address d Type of Building Size Lot............................Sq. feet U ,..., Dwelling—No. of Bedrooms..........3...............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons.........�:................ Showers — Cafeteria Otherfixtures ----------------------------------------------------------•-..........------------•-=-------•-----•------•••--------•---....._••-----------•--------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.........._.gallons Length................ Width................... Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by....................................................................... Date........................................ W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ r, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... 9 ••---•••----•----•----•-••----------------------------------------------------------•--•--•--_---•-•........................................................ 0 Description of Soil----Sand---------------------------------------------------•-•---•--------------------------------------------------------------------------------..........------ U W -------------------------------------------••----•-----------...---•-••-•-•----•-•-----••--•---------•---••--•----------•--------------•----•---•-------------------------•------•----•---•-••--•---.-•• .0 Nature of Repairs or Alterations—Answer when applicable__installation of .. 1,000 gallons pre-cast, stone packed leach pit (overflow . --------------------------------------------------------------------------------------------•--•-------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLiJ 5 of the State Sanitary Code—The undersigned further agrees not top e the system in operation until a Certificate of Compliance en -ssued by the board ---...... ............................ Date Application Approved By--- ----- ��..•- - -----------•------......_..--------------.........._... 8/L��1 83 Date Application Disapprove for a following reasons-----------------------------------------------------------------------------•-------------------..............._ -•-------------------•-----------•---•--...--•--...----------...-•------------------.........-------••---•------------------•-----------------•----••----------------••-------------•-••-•••-----._...._ Date Permit No.-83 --. Issued -8/ /83 ------ Date X No._ _....._...... FEs .... . ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............'i'c�Td2] OF........Pa1ns+Alice--.---------•• ----•------------------•--•---- Allpftration for Biiipustt1 Works Tonstrurtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal System at: fLo•2 �d � ----------- --------N--.--------------------------------•--•------i2fr-aate T � -•---a��• . - or Loto I�I1Ct L J' �yg�s ------------------- Owner.......................................... _....._._..._..---.................._ W f�6 titaterfield Rd,� Orville, ILIA 02655 A & �, �esspoc g � "°�c§nstaiier...........................•---•- 128 3i hps Terrace Sl minis.....�•----6266 -------- Type . of Building q feet U Dwelling No. of Bedrooms......... .................. --.-_Ex Expansion Attic a g— --------- p ( ) Garbage Grinder ( ) p� Other—Type of Building ............................ No. of persons........ ----------------- Showers ( ) — Cafeteria ( ) P4 Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter...--_--__-._- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total.leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution boy. ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date......................................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rX4 Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 •------•---------------------------•----.....-----------....----•---•------..........--•--------••--......................................................... 0 Description of Soil---Saari...................: --------------•---- W VNature of Repairs or Alterations—Answer when applicable..},,t,,,j a.b'_or__of__a__�-�00 fj_.9��ori...P�� t' stot?�--paced beach {over c }� -------------------------------••-•--------•-•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to ce the system in operation until a Certificate of C ha enass ed by the boar e 0, /. Sig d•••--------------•---------._......... �:-------•--... --•----•-............ :... ef...... e Application Approved B - ate---------•- D Application Disappro ed r the following reasons---------------------------------------------------------------------------------------------------•......-----• ---------------------------------------•------••.....--------...•-••-----•----•----------•-------......_........--•--•---•----•--•...-----•---------................................................... Date PermitNoB,-................................................. Issued.-4. -•----•- F ---------..--------.----------- Da THE COMMONWEALTH OF MASSACHUSETTS' BOARD OF HEALTH T.(.�,j.................OF..... ........................................... Tntifirtt#r ,af wnnt rlittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) b B 'r;�ss col"Mice; IZ "Lis�iops TeiY li> e n Ilyar�nis, P!A 62661----------------- --------...•-- --•-•- at126....Tna:�,e�ield �--.l34 -;-•- �-rr-I-lle ...4..--•g � 1471C .... has been installed in accordance with the provisions of TLE "oe Statenitary Code as described in the application for Disposal Works Construction Permit NcL:13-_----------------------------------- dated-%/,--._._.... - -_-.___-.-..--.--------. 3 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARWTEE THAT THE SYSTEM WILL FUNCTIONSATISFACTORY. r l DATE. ... b ............. Inspector............ .A ---------------•----------•----•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................................OF...................................................................... :.............. f , No......................... FEE........................ Big nstt1 Work Tonotrwtion Virrutit Permissionis hereb ra ed > > C -• -----•----_....._.................••--•----------•------....-----••---....------••••-----..._......--..•-•-...--- to Conc ( ) Y n d 1 Sewage Disposal System atNo.................................. G --------••----------------------------------------•----------•---•--------......----------•-------•----•-•--------.... Street as shown on the applica ion for Disposal Works Construction Permit No..-/:.- Dated.......................................... ..................... - -------------•-------..------•-----•--- ----- DATE- Board of Health FORM 1255 A.M. SULK:N;;.,INC., BOSTON S_F/; W1 __jE TOP FOUND. EL 3(, • ,&,5 As Q �xac 2" of 1, Peastone INV. EL 3A.,N'I rM — WA_rrR TIGHT COVER °"�' FLOW LINE 1tY t*w 2, INv, EL. 3 �Z ------ 3_ _ , _'- 1 1, 11as.hed Cy-usc7 .�'tOIIe he 46"UGM 0�711 rC t_T-- I INV. EL. 33 .9`l ( ! Mi—' {-i ( --�-t ,— -_i Y -� r�--------�--- 1 - 1- 2 Washed Cred Stone - T1�et�c1� �d tlj SUMP •. 0 CO1,t �� • '_ r-�1''� C� r?j''.- r_7 1 ao� 1.• us Z INV. EL. 63. S2 I tab ��1 --`--- No. of Trenches / I 1500 GALLON PRECAST REINFORCED CONCRETE SEPTIC TANK No. of 500 Gallon Precast Chambers 7_ AC,_ I KtI ,IF(_iK( F}-i CONCRr T 3%�1" - 1 1; '2" Washed Crushed Stone M*K M CONSTRUCTION MATERIALS PER 310c W 15.M(2) �D!STRlBU'T1 ON 130X 1 TEES SHALL 8E " -- t - --Q �`1 ---�-- � --- -- -------- C0KIMX1E1D Of SCHEDULE 40 PVC AND SHALL EXTEM A IiNl M OF Ir ABOVE THE FLOW LINE rLEVEL Of THE SEPTIC TANS AND BE ON THE CENTERLINE OF THE INSTALL ON A BASE 9 j•r �. SEPTIC TANK LOCATED DIRECTLY UNDER THE CLEAN-OUTWK)IMI'M WALL MANHOLE MINIMUM INSIDE (HMENSIG _ 12" ; � ~:�! �'.. THE MET PIPE! NATION SMALL BE NO LESS THAN 2" NOR 'CUTLET INVERTS SHALL BE EQUAL TO EACH ? -i MORE THAN 3" ABW THE NIVERT ELEVATION OF THE OTHER AND AT 2' MINIMUM BELOW INLET INVERT. OUTLET PIPE. THE DISTRIBUTIOF: LlhlES FROM THE DIc,TRIR0T`IQN gny / 41A SEPTIC TANK SHALL BE INSTALLED LEVEL AND TRUE TO GRADE SHALL A.LL NAVE EQUAL !NVERTS A� CETERM!NEG BY FlGGDION A LEVEL STABLE BASE THAT HAS BEEN MECHANICALLY THE DISTRIBUTION BO'� TO THE HEIGHT OF THE DISTRIBUT10ht �� 1 Z � I i4 W I- } 7 1 27 P� 1" i I COMPACTED AND ON TO W" SIX INCHES OF CRUSH STONE LINE INVERT AF TER ALL LINES HAVE BEEN SEALE('i IN PLACE. HAS 5W PLACED TO E1�WW STABILITY AND 71D PREVET►T INVERT ADJUSTMENTS SHALL HE MADE BY FILLING WITFI DURABLE SET11�K,► AND NON—DEFORMABLE MATFRIAL PERMANENTLY FAST,END TO THE j LINE OR RECONSTF7UCTINIG THE LINES UNTIL ALL I"1`,F>?TS ARE CIF �bl�andl � SEPTIC TAW SHALL HAVE � VE A MINIMUM COVER OF 9-. " L. •�-� ,: i-llii L F FVATI��N e` Note fs}a i i ic+•e=#.b (�� +y .:i^. ..THlttrE so' MIhNHq,LES W11H I�f.ADILY REMOVABLE IMPERMEABLE ,•J COVERS � P � O f - D WITH ACctss should ti(,ils be encountered during sewage syste.m installation that arc -�-1 PORTS B.�1C PLACED A AND OM1IER THE INLET AND _ _ - I OUTLET PEES, not consistent with soil log, contact the designer and/or your la al .L� (::7 UaJ ��P , THE OUTLET TEE PED SHALL BE EQUIP WITH GAS BAFFLE. ' I lealth Department before proceeding. utll/Pol "Al. Rim I;.'. 36.1131 `1 Do t um: VG Y7) I I I General Construction Notes t„� �`�,, ` • �' . - 70 1. All the workmanship and materials shall conform to D.E.P. Title 5 and the Town of `�� Barnstable rules and regulations for the subsurface disposal of sewage. \ r r '�`'39 0 I T R, A t' DI.ST.R1C7` WP 439 - 38 17 ASSESSORS DATit. 119-21 2. At least one access port over tank tees shall be accessible within 6 inches of finish grade, with any remaining access ports brought to within 12 inches of finish grade. RFFFREVCE P&cv 119-97 3. All components of the sanitary system shall be capable of withstanding H-10 loading 57.1 �36 : E' ; unless they are under or within 10 feet of drives or parking. H-20 loading shall be used n, r r under or within 10 feet of drives or parking unless noted. ,' � �, ;' ' ' - - rr- r — - -- 4. The excavator/contractor shall verify the location of all site utilities prior to any a excavation. 'AS 7}rvnch 39 Is'xlsting-- —-- I i •�V — — - 1 - 5. Sewer pipes shall be 4-inch Schedule 40 PVC laid at 0.02 slope. -Dwelling - 25' 6. Any masonry units used to bring covers to grade shall be mortared in place. �_�1 - jo _ - ' / ;N ��' Ut11/Pole r o { GRAPHIC SCALE e — - �- ' 7. Finish grade shall have a minimum slope of 0.02 feet per foot. r\, '� � _ _ _ _ • 0 6 1 , C` zo o ,o zo ,o Proposed SAS F,xpansion so q, d/b 'z•ss' -- QQs- line Soil Logs --� '�v / ( IN FEET ) IB.9 nn�, 1 inch 20 ft Test Date: July 26, 2002 37 ' Siol Evaluator.- Stephen Doyle 37 ' --- --- Proposed 1500 Gallon Tank 38 LOT 10tn Se Wa e System Rep air Plan Pere Rate. C2 Min/Inch DESIGN + 6J150" 39 32156 fsq.ft. — _ Prepared For. Remove Existing Cespools == ;,.,, 1 2 6 Wa t o rfi e 1 d Road STRUCTURE t;k�S� t�w+�t.�Yn� --- l;'a,V and Fill Xlth Clean Course Sand. TYPE NO. BEDROOMS GARBAGE DISPOSAL 89,g ' y �� 1NltlIAM Ix In 0" DESIGN FLOW ;",, OsterVllle, 1'llassa ch use t is -6„ - - --- ----- ------------ ----- ; �, � � ,' yoF Sites Scale: 1" = 20' Date: August 12, 2002 B 1,5 1Ojrr 6/6 -- ---- - ' fs 011A, - " --------- --------------------------------------- - 66 Wide ,' � �d't- Prepared By 24 .� ' Stephen J. Doyle And Associates sEr'Tlc TANK - '�-\S �.� �_-L am�t � _'� �� ,.--------_-__-- � �► 42 C&Oterbury Lane, E. Falmouth, RIA 02536 „C „ ' Telephone: 5041540-2534 Fllti'.E » LEACHING FACILITY o � � — arc 36 --- zs}_z�} •-caZ�- �� x � 4��- Utll/Pole � c vi s s o SAND ,2 5 7.14 P- — — - -- --- -- y: S - ----- _ ------- ------ — _- ----------__ ;' DOYLE No.3755? -1-1 4" -_—-__-. ---------------------------------------- No Ground Water Encountered NO. DATE DESCRIPTION Bl