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HomeMy WebLinkAbout0141 WATERFIELD ROAD - Health 141-.Waterfield-,Road _ �-COsterville A 19 9- 019003 f - 0 I c� Commonwealth of Massachusetts �/9 003 Title 5 Official Inspection Form { } }� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 141 Waterfield Drive Property Address Kim Brown Owner Owner's Name information is Osterville ✓ MA 02655 October 3, 2019 C' required for every page. CitylTown State Zip Code Date of Inspection gat Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms r A. Inspector Information on the computer, use only the tab Patrick T. Sullivan key to move your Name of Inspector cursor-do not Ready Rooter Excavating use the return Company Name key. PO Box 89 Ill Company Address Forestdale MA 02644 City/Town State Zip Code reuan 508-509-0802 SI 12843 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails October 9, 2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts �p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Waterfield Drive Property Address Kim Brown Owner Owner's Name information is required for every Osterville MA 02655 October 3, 2019 . page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) 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", "non or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 yes old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltratiop or exfiltration or tank failure is imminent. System will pass inspection if the existinXthank ed with a complying septic tank as approved by the Board of Health. *A metal septic tank won if it is structurally sound, not leaking and if a Certificate of Compliance indicating less than 20 years old is available. Y ❑ Nxplain below): t5insp.doc-rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 l Commonwealth of Massachusetts �d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Waterfield Drive Property Address Kim Brown Owner Owner's Name information is required for every Osterville MA 02655 October 3, 2019 ii page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or eak 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 approvayf Board of Health): ❑ broken pipe(s) are r laced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is re ved ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution bo 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): I ` ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑)Y ❑ N ❑ ND (Explain below): i 3) Further Evaluation is Required/thend of Health: ❑ Conditions exist which requirluation by the Board of Health in order to determine if the system is failing to protecth, safety or the environment. a. System will pass unlessealth 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: t5insp.doc•rev.7l26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form .Ib Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Waterfield Drive _ Property Address Kim Brown _ Owner Owner's Name information is required for every Osterville MA 02655 October 3, 2019 - page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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 at 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 end the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and S and the SAS is less than 100 feet but 50 feet or more from a priivate water supply well** Method used to determine distance: '*This system passes if the well wat analysis,performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent d the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided th no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other. 4) 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 t5insp.doc•rev.726/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c� Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Waterfield Drive Property Address Kim Brown Owner n r Owes Name information is required for every Osterville MA 02655 October 3 2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. Yes No i ❑ ❑ the s/sten 400 feet of a surface drinking water supply ❑ ❑ the sn 200 feet of a tributary to a surface drinking water supply ❑ ❑ the sed in a nitrogen sensitive area (Interim Wellhead Protection Area mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form p� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Waterfield Drive Property Address Kim Brown _ Owner Owner's Name information is Osterville MA 02655 October 3, 2019 required for every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding'the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® El approximation 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 C Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Waterfield Drive Property Address Kim Brown - Owner Owner's Name information is Osteryille MA 02655 October 3, 2019 required for every ---- page. City/Town State Zip Code Date of Inspection D. System Information 1. 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): 355 GPD Description: Number of current residents: 2 Does residence have a garbage grinder? ® Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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 GPD !, Water meter readings, if available (last 2 years usage (gpd)): 2017=2018= 196 196 GPD Detail Sump pump? ❑ Yes ® No Last date of occupancy: Current Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments ; 141 Waterfield Drive Property Address Kim Brown Owner Owner's Name information is required for every Osterville MA 02655 October 3, 2019 -- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 (jMR 15.203): j Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,-etc.)-. j Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Ti le 5 system? ❑ Yes ❑ No Water meter readings, if available: — - Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Ready Rooter Records: Pumped Spring 2017 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? -- Reason for pumping: .t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Waterfield Drive Property Address Kim Brown Owner Owner's Name information is Osterville MA 02655 October 3, 2019 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information.. System installed 02/29/2003. Certificate of Compliance on file at Health Dept. Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 2.8' 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.): t5insp.doc-rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ti 141 Waterfield Drive Property Address Kim Brown Owner Owner's Name information is required for every Osterville MA 02655 - October 3, 2019 page. CitylTown 'State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2 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: 10.5' x 5.5' x 5' 1500 gallons 3" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 4"at inlet, 1" at outlet 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 14" How were dimensions determined? Dip tube and tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees in place. Liquid level at outlet invert. Risers bring covers within 6" of grade in island. Recommend maintenance pumping every two years. t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•'?age 10 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Waterfield Drive Property Address Kim Brown Owner Owner's Name information is required for every Osterville MA 02655 October 3, 2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal iberglass- ❑ polyethylene ❑ other(explain): 7 Dimensions: Scum thickness Distance from top of scu /tof tee or baffle Distance from bottom of f 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.): 8. 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 t5insp.doc-rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 141 Waterfield Drive Property Address Kim Brown Owner Owners Name information is required for every Osterville MA 02655 October 3, 2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float 7sw' ches, tc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): oilDepth 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.): One inlet, two outlets. Speed levelers in place. Light solids carryover present. Equal flow, no high water staining over outlet inverts. Riser brings cover within 4"of grade. t5insp.doc.rev.7/26/2018 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Waterfield Drive _ Property Address Kim Brown Owner Owner's Name information is required for every Osterville MA 02655 October 3, 2019 page. CityTTown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump ch/er, condittion of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type. ❑ leaching pits number: ® leaching chambers number: 2- 500 gal ea. w/ 4' stone ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.70612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Waterfield Drive Property Address Kim Brown _ Owner Owner's Name information is required for every Osterville MA 02655 October 3, 2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Chambers located and inspected with camera. Liquid level 18"+-below invert at time of inspection. High water staining 1"over current level. Clean stone visible in sidewall. No sign of past hydraulic failure. 12. 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 r� Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflo ❑ Yes ❑ No Comments (note condition of oil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): . t5insp.doc•rev.7r26r2018 rtte 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts _ Title 5 official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Waterfield Drive Property Address Kim Brown Owner Owner's Name information is required for every Osterville MA 02655 October 3, 2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions — Depth of solids Comments (note condition of soil, sig/ofdraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 118 i_ c Commonwealth of Massachusetts �n Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Waterfield Drive x Property Address Kim Brown Owner Owner's Name information is required for every Osterville MA 02655 October 3 2019 State Zip Code, f Inspection Cit /Town C e Date o Ins ect o page. Y P P D. System Information (cont.) 14. 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 0 j a y� 0 3 / 1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 t5insp.doc-rev.7/26 20 8 P 9 P Y 9 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 141 Waterfield Drive _ Property Address Kim Brown Owner Owner's Name information is required for every Osterville MA 02655 October 3, 2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ' ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >5 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. 03/06/2002 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: maps.massg is.state.ma.us/oliver.ph You must describe how you established the high ground water elevation: Test hole in 2002 to 126" (elv= 59)found no ground water. Base of SAS at elv=64.2 per engineered plans. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Waterfield Drive Property Address Kim Brown Owner Owner's Name information is required for every Osterville MA 02655 October 3 2019 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria) and 6(Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached' For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 i TOWN OF BARNSTABLE 0• `1 LOCATION ��i Gti�.��v,, �1 �Cycz SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. n�- f SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) S''O cp NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: ©`' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by s V i i �� ,Z/p's Nb. ��-�U-\=7L� THE COMMONWEALTH OF MASSACHUSETTS FEE/I BOARD OF HEALTH ��� OF APPLICATION FOR MSPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) - Complete System ❑Individual Components m a p 1 1 ry G( o y — 6 03 Owner's Name — - 1 Map/Parcel 1 # Address L't# Teleph ne#r Installer's me Designer's Name Ll f-.J, 6-rr y Address A r Telephone# Telephone# Type of Building: Lot Size Sq.feet Dwelling—No.of Bedrooms Garbage Grinder " Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min.required)_ `2 ) gpd Calculated design flow gpd Design flow provided gpd Plan:rDate Number of sheets Revision Date Title D`e�cription of S 1(s) � �- �U h_ d' 5� Soil Evaluator Form No. Name of Soil Evaluat r • t t i Date of Evaluation 3 DESCRIPTION OF REPAIRS OR ALTERATIONS 5 1 r The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a not ce the stem in operation until a.Certificate of Compliance has been issued/y�e Board of Health. _ ___. / Signed "� Date �` Z `� ^? A FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 .-• . r- ,.. :.t'' r" .r .•.rw."•''ti"•.r,fa� .c L ., l _ • `� -.,^.. i /b. COMMONWEALTH OF MASSACHUSETTS FEE I �J i A BOARD OF - HEALTH �•� OF Y +� .;APPLICATION FR"pISPOSAL SYSTEM CONSTRUCTION.PERMIT �. Application for a Permiito Construct ( Repaii;,( )_Upgrade"'( ),Abandon ( ) - Complete System ❑Individual Components X Location Owner's Name r .•, Mao o I l i ��� �j i� 6 63 s" Map/Parcel# Address O 9 pr • Lot# Teleph ne# � Installer's me Designer's Name a '! Address { r Abe r I Telephone# Telephone# Type of Building: Lot Size Sq.feet Dwelling—No.of Bedrooms Garbage Grinderj� r Other—Type of-Building No.of persons Showers ( ), Cafeteria ( , ) Other fixtures Design Flow(min.required) 55 gpd Calculated design flow35 gpd Design flow provided MF43 gpd Plan:,-` ate `' -0 Number of sheets Revision Date Title t 14 Description of So (s) �V LWAkA "-4 , ttyvwv LJ, ,`I- Z V w - Soil Evaluator Form No. Name-of Soil Evaluat r• -t A,1A I'ale; Date of Evaluation V y� t DESCRIPTION OF REPAIRS OR ALTERATIONS 'T 1WZ 3 The undersigned agrees to.install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not place the ystem in operation until a Certificate of Compliance has been issued by a Board of Health. _--�� Signed ✓ �"�� z'�� � i, Date �'•��" d GIaspeetiens-�k ';, i `FORM 1•�' APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No.-,_ C_- 3U� THE COMMONWEALTH OF MASSACHUSETTS FEE ►�rLP \�1�� BOARD OF HEALTH f CERTIFICATE OF COMPLIANCE ` Description of Work: In ividual Component(s) .a E' omplete System The undersigned hereby certify that th Sewage Disposal System;Constructed(v),Repaired( ),Upgraded( ),Abandoned( ) has been installed in accordance with the p,cr�o� visions of 31 CM R 15.00 (Title 5) and the approved design plans/as-built plans relating to"application No?U2, '_s,ue dated Approved Design Flow (gpd) / Installer ��rV�///�cJ�]/��// �y//J/(�� y�//]/� � /� �I/�(/� wo,-L3 Yll .1 J i_I ,fA.T.M1.A//FA,� ./ r Ys � Designer: Inspectoi•�' �. , J � l Date f ✓ v The issuance of this certificate shall not be construed as a guarantee that the/system will function as designed. a FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 { No7(_-�02 - LUG THE COMMONWEALTH 0J1r MASSACHUSETTS FEE I BOARD rOF HEALTH ',DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct E✓ Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system at y '=° �,,-Q �'t p ICA 2!1, � C­R Vj as described in the application for Disposal System Construction Permit No. Z.t�J2 '��� dated //R /CR Provided: Construct* n shall_be e completed within three years of the date of this er it.. l;li dal d ditions u'st e-met. Date ."Board of Health T FORM 2 - DSCP DEP APPROVED FORM 5/96 U vr IN / FORM 1255 (REV 5/96) H&W HOBBS&WARRENrM PUBLISHERS - BOSTON t TOWN OF BARNSTABLE LOCATION /' / ����re SEWAGE # I VILLAGE r'`/s ue J ASSESSOR'S MAP& LOT IN. INSTALLER'S NAME&PHONE NO. �zSEPTIC TANK TANK CAPACITY LEACHING FACILITY: (type) (size) SQ NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE:-7/jazic>)_ COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by /113 _Z/o,�,. PROJECT TITLE �I�Gn�SC � {� Y.Ji� (yam- •. i < L-0� my Vw r � _ R _ F XT � �••j PREPARED FOR rC� E E. _. n ng, t- Ce tra( Cons ti C pa truc on om . Z8 Steve Devlin Pmident 261 Blackthorn Drive•Marnons IN,1Is,MA 02648.508=420-1340 r' SCALE,k= I t _ Frov, 1- U _ -- �. o DATE 4 dZ DWG NO. DESI`GN v i CHECK DRAWN etV- rZ vZ . — -- IV�,C'St Scf-eciuro'1 PROJECT TITLE • -- _..�4K cis. .. - (S�rt3:etn ti ; .. _.. __ .�.I�ci��os�� .._RCS%�cb►_C�_ Zg�6 .,►�rlhcN / 3AT', L(SSL 305Z- ` \ ti ---wig R r ri flX, -- - \ 1. -t PREPARED FOR — 6 56�6 z8'i,6 ® _ SrcP - o 20 Central Construction Company, In b y Suve.Devlin •l3rsiknt Ys �� FL O :�:_..._. Y- -- -t - 261 Blackthorn Drive•Marsions 0' ,AM 02648.508 4201340 � � - - • - SCALE \ O d' \ DATE / 1.0L DWG NO. DESIGN tiUt / CHECK DRAWN V— pZ. _ JO®,NO. ISHEET OF 'F SYSTEM PROFI CATION FINISHGRADE FINISH GRADE OVER NOT TO SCALE ,0 EL.69.5 SEPTIC TANK 69.0 �-RISERS TO 6" OF FINISH GRAD r o � 3RADE OVER ;UTION BOX 68.0 3"MIN. FINISH GRADE o MIN.SLOPE 1% :a OVER TRENCHES 68.0 6" MIN.SLOPE 1% RISERS TO 6" . MIN OF FINISH GRADE e PRECAST CONCRETE �! b' 500 GALLON DRYWELLS 13„MIN. 14„ 67.40 67.00 `o OUTLET PIPE(S) LEVEL H-10 REINFORCED LOADING MIN/ 66.75 FOR 2'( MIN.1% SLOPE TRENCH LENGTH = 25'-0' PVC OR CAST IRON TEES `y BEYOND 6 GAS BAFFL a ,6 'r DRYWELL LENGTH = 8'-6" 1500 GALLON w _ E61 - 16-SUMP :, ,o i,' w.-,o�p': ° '' `A' `'v cti , :' ,ti./., „O°T ,.• :i' ': ., Q :, ., O .lzPRECAST CONCRETE _� -�= ° �'�• ,o %a., �: 'b b°,o ,o ,.Y� U o:po 01, . SMT.FLR. `o'- =;� H-10 REINFORCED a 'RIBUTION BOX 6 - 4.2 LEV.63. - ti EL.6 5 0' ,� . 1 . -� 4 '; INSIDE DIMENSION 12 3/4 -1-1/2 DOUBLE 4° °,;j %- � �• „ 3/4"- 1=1/2"DOUBLE , '► RTS 2 BELOW INLET INVERT 4' WASHED CRUSHED 5 2 4 WASHED CRUSHED /, i q.o ;9S • °,• 6'' ' ;o' ° '\ �` '•i ° 07 ICRETE WALL THICKNESS 2" STONE STONE S 8 4'0 ., SEPTIC TANK � • _ •� -- �� COMPACTED LEVEL BASE . 0 E o. °g , BOTTOM T.H.#1 EL.59.0 216.311 INSTALL ON COMPACTED LEVEL BASE 0 a 1 TRENCH SECTION NOTE: EXCAVATE TO=C= STRATUM IN ORDER TO REMOVE ALL =A= &=B= IMPERVIOUS MATERIAL �` " • 6 WITHIN 5'OF THE SAS, REPLACE WITH CLEAN, 9„ „ „_ „ MIN. 3 OF 1/8 1/2 • ° " ° CLAY-FREE SAND. 6" MAX. DOUBLE WASHED 0. • ; 4" DIAM. PEASTONE 10 LOT 4 43,560 SF. :, " 3/4". - 1-1/2" DOUBLE r WASHED CRUSHED Po x .. . _-.__. ,.- ..•._., '48., 5'-211 I „ STONE TRENCH WIDTH 13'-211 ls.00' 28.00' 2.ALL PITONS 1. ELEVA TIO f. 32' � OTES: - _ - NUMBER OF TRENCHES 1 ' ;, - fP�9 - NUMBER OF DRYWELLS 2 PROPOSED OR SCHEDULI BASED ON ASSUMED 3 BDRM.HSE. N 3. HEALTH AGEI I'vil' T BE CAS I 'R�, 1 OBSERVATION PIT ,�, �� i8.00' w MUST BE NOT 40.00 _ COMPLETE PF P-10183 �, LANDS ENGINEERING a i sa o N 4.ANY CHANGE PERCOLATION RATE: < 2 MINJIN "' BY CAPE& ISL CONSTRUCTION IS es, I `�' o OF HEALTH. KFILLING. WITNESSED BY: D.STANTON z 4N:MUST BE APPROVED BARNSTABLE BOARD OF HEALTH j & 5. MATERIALS A IEERING AND THE BOARD DATE: MAR.6,2002 0 6 COMPLIANCE T.H. #1 &.#2 SAME DESIGN DATA. \ j f [TITLE V]AND ! kTION SHALL BE IN 0" r I REGULATION 'ATE SANITARY CODE =Aw= LOAM I I I 6. NORTH ARRO ICABLE RULES AND 10 YR 2i2 NOT INTENDEI 6„ R NUMBER OF BEDROOMS 3 68 j RESERVE r 7. WATER SUPP ZECORD PLANS AND IS GARBAGE DISPOSAL NO j _____ N _ 8. FLOOD ZONE Z ENERGY PURPOSES. =B= LOAMY SAND DAILY FLOW 330 GPD. \ r 9 FLOOD PANEL 10YR 5/4 j 68 aL WATER SYSTEM. SEPTIC TANK REQUIRED 1500 GAL. • , I I 10.THIS PhOJE( I ARDJ 42" SEPTIC TANK PROVIDED 1500 GAL. \ I W CAT x GROUND DISI 6 D DATED: JULY 2;1992 LEACHING REQUIRED 330 GPD. , WITHIN 100 0 f INVOLVE ANY PHYSICAL I.� BANKS OR FLU w R VEGETATION REMOVAL SOIL ABSORPTION SYSTEM CALCULATIONS: INLAND OR COASTAL N I Q I )ZONES. =C= MEDIUM SAND p I I w I 10YR 7/4 SIDEWALL AREA= 152 SF. j 152 SF. X .74 G/SF'. = 112 GPD. BOTTOM AREA= 329 SF. 1 25.88 . 52 329 SF. X 0.74 G/SF. = 243 GPD. `i s 88°26'44°E 126" NO GROUNDWATER LEACHING PROVIDED = 355 GPD. DcoNTouR SINGLE FAMILY RESIDENCE 1 Y CONTOUR ' CONC.BU. , EL.75.6 o� Q;r�� y' <•kA PROPOSED SEWAGE DISPOSAL SYSTEM 40.24' 644„E ❑ fIUN PIT yr: to L,,. f >`• PREPARED FOR . tit r r• t ,,'-: o -late Box z �;. t; CENTRAL CONSTRUCTION ;:�,�; -" HSE.NO. 141 (LOT 4) WATERFIELD RD. '0.56, - - OSTERVILLE,MASS. � ►NK Q a RESERv� )RPTION SYSTEM w w Q x PLAN No. 031802 SCALE:AS NOTED r ;� 0F y s FILE NO. DATE: MAR.18 2002 ti 22.26 AREA , i N ems;` M � �`, SEPTIC FILE 1�0. 71 PCS FILE: WATERFIELD W Q RT ELEVATION sANiCr;i ) PLOT PLAN 119 A 28035 CAPE & ISLANDS ENGINEERING SCALE: 1"=30' MAP �_003 R R o w�ss N�r1S7,c,�o`%�/�* 800 FALMOUTH ROAD, SUITE 301C