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Commonwealth of Massachuseifis
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments•
y. 5 tin;Ec r�n;lrirn rlarLE
2.
Property Address
RON HALEY
Owner Owner's Name
information is OSTERVILLE required for - MA 02655 7/15/2009
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.
When Important: A, General Information
When filling out ,
torms on the
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A.BROWN
use the return J
cursor- not Name of Inspector
key. DOUGLAS A. BROWN INC
Company Name
P.O. BOX 145
Company Address
CENTERVI LLE MA 02632
City/Town State Zip Code
508-420-4534 S14297
Telephone Number License Number
B. Certification
1 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 insp4d-On. The inspection=
Aes ner€nr-mad based on my traininn anct avnoriani a in Oho nrnncr fi ine,inn and mgini`Gh�nra Af nnycePg
sewage disposal systems. I am a DEP approved system inspector pursuant to Sebftop 15.340 6? -4a
Title 5(310 CMR 15.000).The system: --
9
® Passes ❑ Conditionally Passes ❑ Fails 11
❑> Needs Further Evaluation by the Local Approving Authority
�� tJ
7/15/09
Inspector gnature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use...
N
t5ins•09A8 Title 5 Official Insp
ection Form:Subsurface Sewage Dsposal System•Page 1 of 17
4
Commonwealth of Massachusetts
Title 5 Official. inspa ctLnn Form.
I� Subsurface'Sewage Disposal System Form=Not for Voluntary Assessments
235 WEST WIND CIRCLE
Property Address
RON HALEY
Owner Owner's Name
_farm�c�.
required for OSTERVILLE MA 02655 7/15/2009
every page. City/7own 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.Rases
® 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:
SYSTEM;MEETS PASSING RE100 REIMENTS_AT THIS TIME
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 forges", "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.09M8 Tine 5 Official inspecUon Fuji[SuL-s iiiaue Sewage Disposal System•Page 2 or 117
e
Commonwealth of Massachusetts
PAM
Of
■ ■r V .Y ■Y■N■ ■■■ YY r■ ■ -
Subsurface Sewage Disposal System Form=Not for Voluntary Assessments
235 WEST WIND CIRCLE
Property Address
RON HALEY
Owner Owner's Name
requiredfor OSTERVILLE MA 02655 7/15/2009
every page. Clryfrown State Zip Code Date of inspection
B. Certification (cont.)
B) System Conditionally passes(cont.):
rum Oh-pen ativn,nf ec; na h��kxin nr,hrb :n. .nr h:static ter a11nl in. h r� �•
.. � ••-r �, .tt... h y.. ...,0'"2. ..t 9 ! tr t;nn mv.wl�a-
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, El 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) 'FurtherEvaluation 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,pnvv s::*thln 50;.feet of;a bo derma veaetatedsvvetland_;or a sa#..marsh._
Y
LSins•09Ig8 : Trde 6 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Ti la 5 1' #ir.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 235 WEST WIND CIRCLE
Property Address
RON HALEY
Owner_ Owner's Name
re
q;,fired for r�V OSTERVILLE
MA 02655 7/15/2009
every page. Cityf own 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.ar d_anvirme onnt-.
❑ The system has.a septic tank and soil absorption system(SAS)-and the SAS is within
100 feet of a surface water supply_or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply:
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen,is equal to or .
less than_ nnm;.provi#edi that na other_fatlk �.rit�na are tnnn red A.,rt�oa.of_the analysis rhiastu hs,.:
attached to this`form:
3. Other:
D) System Failure Criteria Applicable to All Systems:
You mu—st_indicaats."Yes.."_d-.!'No"..to a—a—E2 oUtha,.€nllcskvr _fnrc.atl,i{a earti�n�;..
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
n ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less'than 6"below invert or available volume is less
than %day flow
tsms•osros
Title 5 Offal Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Ti#! 01f#er.e.a.l. lese��ar#e�I:� �nr
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
235 WEST WIND CIRCLE
Properly Address
RON HALEY
Owner Owner's Name
required for OSTERVILLE
every page. City/7own MA 02655 7/15/2009
State., Zip Code- Date of Inspection
B. Certification (cunt.)
Yes No
M M 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,O00gpd.
M 1711 The system fails. I have determined that one or more of the above failure
criteria exist as described In 31u CMK 1b.3u3,therefore the system tails. I he
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
.11V J JlVlll is.—thin of
G't114111G1 lV q JMI IGIV�r dr'1111\II1�YYGtVr JV pnI..
y b
❑ ❑ 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
e
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 31 u c:MR 15.304.The system owner shouid contact the appropriate
regional office of the Department.
t5ins•09i08 l Tide 5 Official Ins pecton 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
235 WEST IA11ND CIRCLE:.
Property Address
RON HALEY
Owner Owner's Name
information is OSTERVILLE required for MA 02655 7/15/2009
every page. City/Town State Zip Code - Date of Inspection
C. Checklist
Check if the following have been.done. You must indicate`yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ E 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?
[J Were 2S:.DNnl4 plans of 4he c�icioni rihf2inoel�nrV a amine_?(I#4tie1/.FrePo n:?
r...._ _� ... �.. _�
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑. Was the site inspected for signs of break out?
Were all system components. excluding the SAS. located on site)
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid,depth of sludge and depth of scum?
❑ ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems? '
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
❑ ❑, Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]'
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins-09M
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
1 ,
Commonwealth of Massachusetts
Ti les 4 rial Inim-not.#inn 1=or
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Subsurface Sewage Disposal System Forma Not for Voluntary Assessments
a
235 WEST WIND CIRCLE'
V '
Property Address
RON HALEY
Owner Owner's Name
J
required for OSTERVILLE
every page. Cityli own MA 02655 7/15/2009
State Zip Code Date of Inspection
M' System Information
Description:
ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1000 GALLON TANK, D-BOX,AND
TWO 500 GALLON CHAMBERS
Number of current residents: �0
Does residence have a garbage grinder?
0 Yes ❑ No
Is laundry on a separate sewage system?[if yes separate inspection'required] ❑ Yes ❑ No
Laundry system inspected?f ❑ Yes ❑ No
Seasonal use? -
El Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)): 06-283/07-503
Detail:
ACCORDING TO OWNER TENANTS 1N 2007 USED EXCESSIVE WATER
Sump pump? ❑ Yes ❑ No
Last date of occupancy:
Date
f ommer6al lnndustrial Flew rnnditinn5:
Type of Establishment:
Design flow(based on 310,CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.):
Grease trap present? El Yes .❑ No
Industrial waste'holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ,, ❑ Yes ❑ No
:' ,ter,meter readings, if
t5ins•09/08 '
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 .
Commonwealth of Massachusetts
Title■�r■Y Y r/ ■■■V•N■ •■■V�YVr■Y■• • V■ ■•■
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
235 WEST WIND CIRCLE
Property Address
RON HALEY
Owner Owner's Name
required for J OSTERVILLE MA 02655 7/15/2009
every page. Crty/Town State Zip Code
Date of Inspection
D. System Information (cont.)
Last date of occupancy/.use:
. Date
Other(descriha hgIn-) '
't
General Information
Pumping Records:
Source of information: OWNER PUMPED IN 2008 FOR MAINTENANCE
Was system pumped as part of the inspection? ❑ Yes ® No
if o n.volumeq
.. .
gallons
How was quantity pumped determined?
Reason for pumping:
I
Type of System:
Septic tank, distribution box, soil absorption system
El Single cesspool
❑ Overflow cesspool
I
❑ y
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
i ❑ 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);
r Y
t5ins•09/08 Title 5 Official Ins
pection Form:Subsurface Sewage lAsposal System•Page 8 of 17
i ,
Commonwealth of Massachusetts
■ RIO 5 Official Inenar#inn Fnrra�
■ ■r■Y Y \/ ■■■Y■N■ ■■■Y�YYr■Y■■ ■ Y■ ■■■
Subsurface Sew%age Disposal System Form=Not for Voluntary Assessments
235 WEST WIND CIRCLE;
Properly Address
RON HALEY
Owner_ Owner's Name
required for OSTERVILLE MA 02655
every page. Cit Awn 7/15/2009
State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known) and source of information:
7 YRS OLD OFF AS-BUILT CARD '
Were sewage odors detected when arriving at the site? El 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:
I -feet
C.nrnments inn condition of inintc vgntinn evir■enng of IPaka?p gtr.•):
Septic Tank(locate on site plan):
{ ,
Depth below grade: 5
feet'
Material of construction:
®concrete ❑metal ❑fiberglass ❑polyethylene
❑other(explain)
If tank is metal, list age:
}• years
IS age confirmed by a Certificafe of f omnlinn,i, (atfianh a nnnu of rrrrtifir atal I—1 ;�pc ("� Kin
_...r.. —..--.. — _ter, _.
Dimensions:
Sludge depth: t +
t5ins•09)D8 I -
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
a ,
7
Commonwealth of Massachusetts
Subsurface Sewage Disposal System Forma Not for Voluntary Assessments
235 WEST WIND CIRCLE
Property Address
RON HALEY
Owner Owner's Name
requiredforJ OSTERVILLE MA 02655 7/15/2009
every page. Cltyfrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
liet?nre from ton of elLirtno to bottom of oidlct tee or S_nffta
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
f
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
TANK LOOKS CLEAN AT THIS TIME
{ u
m
Grease Trap(locate on site plan):
Depth below grade:
k
feet
M?te.rinl of rnnctn irtinn
❑concrete ❑ metal ❑fiberglass ❑ polyethylene
El other(explain):
1 _ .
Dimensions: ,
$rtiim thirknAec
Distance from top of scum'to top of outlet tee or baffle
- d
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
•" Date
Tidp 5 Official Insper-Wn Form:Suh-jrfare S?wa e.[Ac
. S- -F'�al SyF±am•PagP 1Q of 17
' i
Commonwealth of Massachusetts
Mza T'ifla A f)fer-iai Inansar-fine Forlm
■ .�.v v r ...v.v.. ■..vrvv...v.■ . . ... -
Subsur.'ace Sewage Disposal System Form-Not for Voluntary Assessments
r 235 WEST WIND CIRCLE
Property Address
RON HALEY
Owner Owner's Name
requiredforN OSTERV►LLE ,MA 02655 7/15/2009
every page. Coy i own 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 Molding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
5
( l rnnrratg ICI metal f l'Fiberi lacc I-1 nnlvAthvlana. ❑nthgr faYnlninl-
Dimensions:
Capacity:
gallons
De.Sinn Fln_•,nr-
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.):
r
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
tsins•09M8 •
Title 5 Official tnspectron form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Teflsa 5 (Iffereal lnsnar#ern �r%rm
■ ■�■Y Y �/ ■■■Y■N■ ■■■V V V r■V■■ -■ V■ ■■■
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
235 WEST WIND CIRCLE
Property Address a
RON HALEY
Owner Owner's Name -
required for OSTERVILLE MA , 02655 7/15/2009
every page. City/Town state Zip Code pate of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
L)enfh of Urn6H;oval nhn�ra n�rtlof inuart 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.):
p
S
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑`No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of,pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan,excavation not required):
If SAS not located, explain why:
t5ins•09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 12 of 17
t
i
Commonwealth of Massachusetts
■ ■�■w v w ■■■w,■v■■ ■■■wrswv■,■w■■ ■ w■ ■■■ .
Subsurface Sewage Disposal System Forme Not for Voluntary Assessments
235 WEST WIND CIRCLE
Property Address
RON HALEY
Owner Owner's Name
re ,iredforJ OSTERVILLE MA 02655 7/15/2009
every page. cdyi I own State Zip Code Date of Inspection
D. System Information (cont) .
Type:
lannhinn nifc
r.._ n!•mhar
® ' leaching chambers number: 2
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions.
❑ overflow cesspool number:.:
❑ innovative/alternative system
T.,nnlnn..:n of innhnology: -
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil, condition of
vegetation, etc.):
OPENED CHAMBERS THEY ARE ABOUT 1/2 FULL AT THIS TIME
i
i .
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Ah_is-ihar nnri rnnfirn ir�4inr
Depth—top of liquid to,inlet invert.
Depth of solids layer
Depth of scum layer `
t
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Dina•O LUE Tifte 55 O" 'roll inwecbon For:Subau.ace Se:rae DaDmai Svatem>t'aae 13 of 17
Commonwealth of Massachusetts
r Sul;surface Sewage Disposal Systern Form. .Not for Voluntary Assessments
't 235 WEST WIND CIRCLE V .
Property Address
RON HALEY
Owner Owner's Name
required for OSTERVILLE MA 02655 7/15/2009 a
every page. Ci yfrown State Zip Code pate of Inspection
D. System Information (cunt.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
E °•
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of sok-1-
Comments(note condition of soil,signs of hydraulic failure, level of pondii-lg,condition of vegetation,.
etc.):
`'
Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
• o
Commonwealth of Massachusetts
z Tifin (Iffir-iat InSnar-finn �'nrm
.. ......p.......... ... ...
Subsurface Sewage Disposal System Form=Not for Voluntary Assessments
235 WEST WIND CIRCLE
Property Address
RON HALEY
Owner_ Owner's Name
is
required for OSTERVILt_E MA 02655 7J15/2009
every page. City/Town 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 buildina. Check one of the boxes below:
El hand-sketch in the area below
® drawing attached separately
6
fts•Q9M
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts : Fl
■ ■�1■v v v■■■w■v■■ ■■■vrsvv�■v■■ ■ v■ ■■■
Subsurface Sewage Disposal System Form o Not for Voluntary Assessments
235 WEST WIND CIRCLE
Properly Address ,
RON HALEY
Owner Owner's Name
required for OSTERVILLE MA 02655 7/15/2009 .
every page. Ciiyrown State Zip Code Date of inspection
D. System Information (cunt.)
Site Exam:
chock ch,o ,
® Surface water .
® Check cellar
® Shallow wells
Estimated depth to high ground water' 101++
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
ra Ck_-Cl-.a .r..+ s :.... .�..... a.
11 IVVI\V V,.VGIC V VCr;g.1 pla. II�iY IV fYVM.
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:
AUGERED TO 12' IN BACK YARD NO G.W ENCOUNTERED
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5;ns.09A6
Title 5 Official Inspection Form:Subsurface Sewwe Dspcsal System•page 16 of 17.
Commonwealth of Massachusetts
Subsurface Sewage Disposal System Forma Not for Voluntary Assessments
UiW.. z
235 WEST WIND CIRCLE
Property Address
RON HALEY
Owner Owner's Name
required for J OSTERVILLE MA 02655 7/15/2009
every page. cdy>i own State Zip Code Date of Inspection
E. Report Completeness Checklist
® inspection Summary:A, B, C, D, or E checked
c..,..,-14;^n c...,,:„,,;,n ie,..•....,ca:lurc C.flan.Applicable to All
+...,.� c..a.a
n wra.vuvn vun a naa�y v w�uaa.n w a,vnaa.�iu`-aNrua,aav�a. v�n YrtC -1 w—i—1-1a.aa
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins 0910E Title 5 Official hcspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal i System Form -Not for Voluntary Assessments
235 WEST WIND CIRCLE
Property Address
RON HALEY/KRH PROPERTIES
Owner Owner's Name
information is Qa2
—IS-5`
required for LE Oj+ef-,)[�,c- MA —02632— 7/15/08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
S' sS
11011 ,2
" 3-1
0 `t 0
Title V Inspection Form.doc•08/06
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
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DEPARTMENT OF ENWR®NMI ENTA% PROTECTION
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-TITLE 5
OFFICIAL INSPECT'IOi�r ORIM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM F€.3R1M
PART A
CERTIFICATIOIN
Property Address: 3 j yle /o� / v/.f
Owner's Name:
Owner's Address: cle
ate of Inspection: q t
Dame of inspector:r I print)
Company Name; . Cer P11'n�l
Mailing Address: 57,n kQ
e-i-i2 v. Wl�t o 6`E i
"telephone Number: ,��
i
CERTIFICATION S T ATEMENT
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 15340 of Title 5(310 CviR 15.000). The system:
'Passer
Conditionally Passes
{,Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: L:jo A 6
Bate: 7a
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional of ice of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
audhoriry.
Notes and Comments
****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.
Title 5 Inspection Form 6/151-7000 page I
R
1
e2otI
OFFICIAL SPEMON FORM—NOT FOR VOLUNTARY ASSESS l S
SU R nCE SEWAGE MSP SYST l!NSPEC IL 44`?�►N ii!ORiv1
PARS A
C'ERTMCATION(continued)
Property rl,ddress:
0
t-IA'k-Vlip
meter:
Date of Inspection•_, .,;2
T
Inspection Summary: Cbeck A,B,C,D or R!AI WAYS complete aHH of Section D
A. Systems Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
1531}3 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:.
I8. System Conditionally Passes:
One or more system components as described in the"Conditional "section need to be replaced or
repaired.The system,upon completion of the replacement or repair approved by the Board of health,will pass.
Answer yes,no or not determined(Y,N;ND)in the for the following statements.If`snot determined"please
explain-
The septic tank is metal and over.20 ears old*or the septic tank(whether metal or not)is structtmally
t$solmd,exhibits substantial infirm r exhlt*ation or tank failure is munment System will pass inspection if the
existing tank is replaced with a corn a septic tamk as approved by the Board of health.
*A metal septic tank will pass' on if it is strttally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less 20 years old is available.
ND explain:
=Jon sewage backup or break ma oar stag water level in the distnibutiOn box due to broken or
obstru or due to a broken,settled or uneven distribution box.System will pass mspection if(with
approval of B of Health):
broken�e(s)sire rqdwed
obs is�moved
distrTib box is leveled or replaced
explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The systaM will
pass inspection if(with approval of the Board of health):
broken pipe(s)are replaced
obstruction is removed
NTD explain:
2
fags �_
OFFICIAL INSPECTION ION MU —NOT FOR-VOLUNTARY ASSFSSV. tEN, -I S
SUBSURFACE SEWAGE DISPOSAL SYS I 9SPE ION FOR-M
PAR 1 A
CERTIFICATION(continued)
Property Address:
Owner: �e
Date of lnspection
C- Further Ev2l112tion is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in er to determine if the system
Is fallulg to prfltect public health;safety or the environment.
1. System will pass unless Board of Health determines in accords se with 310 CMR 15303(1)(b)that the
system is not functioning in a manner which will protect pu tc 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 v ,etated wetland or a salt rrsar-,zh
?. System will fail unless the Board of Hea (and Public Water Supplier,if any)determines that the
system is functioning in a manner that pro is the public health,safety and environment:
_ The system has a septic tank an soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary t surface water supply.
The system has a septic and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a sep " tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a :c tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply ell**_Method used to determine distance
**This system es if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and vol ile organic compounds indicates that the well is free from pollution from that facility and
the presence o ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure crite, are triggered.A copy of the analysis must be attached to this form.
3_ Oth _
3
Pe4o€Il
OFFICIAL INSPECTION FORM—NOT FOR VOLUN7ARY ASSESSI NT
SIBSIWAGE SEWAGE D- MM INSPECTTON EGA
PART-A-
GEIt CATION(continued)
Property Address: / P$7� C t (L'l e
Owner-.
Date of lnspection: IQ '66 —
a
1- Systems Failure Criteria applicable to a:l systems:
You must indicate`Yes"or"no"to each of the following for ail 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 ligWd 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 vohtaie is less than'/=day flow
— Required pumping mom than 4 times in the last year AdOT 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 widdn a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply weir.
— 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.jThis system passes if the well water analysis,
performed at a DEEP certified laboratory,for cafiform bacteria and volatile organic.coompourAs
indicates that the well is free from pollution from that facility and the presence of ammonia �
nitrogen and nitrate nitrogen is equaf to or less than S ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.}
(Yes/No)Tit system faft I have determined that one or more of the above failure criteria exist as
described in 310 C!,M-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.
L. Large Systems:
To be considered a large system the systems must serve.a fa with a designnow of.IO,f;63Q gpd tc 15,41
You must indicate either"yes''or"no"to each of the owing
(The following criteria apply to large systems it ,to the criteria above)
yes no
— the system is within 400 fee f a surface drinking water supply
the system is within feet of a tributary to a surface drinking water suPPly
— a
— the system is l ed in a nitrogen sensitive area(Interim Wellhead Protection Area—TWPA)or a mapped
Zone II of a blic water supply well
If you have ed"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Secla D above the large system has failed.The owner or operator of any large system considered a
S gwficant -eat under Section E or failed under Secvon D shall upgrade the system in accordance with 310 CNM
15.304. a system owner should contact the appropriate regional office of the Department
4
rzsc vi:S
-
O �iV OFFICIAL SPECTIO FORM—NOT FOR VOlE L ARY ASSESSNIMNTS
SUBSURFACE SEEWAGE DISPOSAL SYSTEM LNSPECTIO�i sOWN11
PART B
CHECKLIST
Property Address: Av 5Oe� i +� C`�
Owner:
Date o,Inspection:
Check if the following have been done.You must indicate"yes"or`�no"as to each of the following:
i
Yes NO
_ Pumping information was provided by the owner,occupant,or Board of Health
�A Were any of the system components ptunped 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 mote as NVA)
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 flee_baffles or tees,material of constriction,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
6ainle�ce of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site bas been determined based on.:
Y no
Existing in bamation.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 Determined in the field{if any of the failure criteria related to Part C is issue approxim ion of distance
is unacceptable) CMR 15 302(3,Kb)]
r
5
Wage 6 of=.
}
OFFICIAL ISI't;!C`1-1!JN $OIA1a— 0 T FOR VOt.,J,4-T i° SE 1 �`g`S
SUMSL 'EICE SEA VAGE DIS Sam SY- 1EM INSPECTIO?c FORM
PART C
SYSTEM IIVF'OI2MATIONT
Property Address - %fy,f4Q
Owner:
— '
Date of Inspection:_—f_ oDL Q C7C5
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(desist): Number of bedrooms(actual): —3
DESIGN flow based on 310 CMR 15.203(for example: 1 i 0 gpd x it of bedrooms):
Number of current residents: 0
Roes residence have a garbage grander(yes or no): AID
Is laundry on a separate sewage system(yes or no):AJO [if yes separate inspection required]
Laundry system inspected(y or no): b
Seasonal use: (yes or no):!�
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): $10
Last date of occupancy:
COMMERCIAL 14DUS TILL {
Type of establishment:
I3esigr,flow(based on 31fl CMR 15.2 ': pd
basis of design,flow(seatsfperso-• f<,etc.):
Grease trap present(yes ar no):
Industrial waste holding resent(yes or no):`
Nona sarkLrly waste d=sch ged to the Title 5 system(yes or no):
Water meter readings, available:
Last date of occup y/use:
OTHER(des ae):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): a V
if yes,volume pumped:_gallons—How was quantity pumped determined?
Reason for purnpiw
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 dzy)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _attach a copy of the DEp approval
_Other(describe):
Approximate age of allN,popents date installed(if kanown)and source of informazioan:all �e got
Were sewage odors detected when arriving at the site(yes or no):IV�
6
azet w
OFFI UL SPEC'-QO FORM-1 _NOT FOR VO UNg A Y SSE I t S
SI;isSI, CE.SEWAGE DISPOSAL SYSTEM Pr SPEC T IO FORM
PART C
SYSTEM INFORMATION(continued)
Property Address S� �c.,��1 j off,ce
t �
Owner: -e
Date of Inspection: —�
BUILDING SEWER(locate on site plan) .
d�
Depth below
Materials of construction:_cast iron —,�40 PVC_other(explain):
Distance from private water supply well or suction line:
Con—_.ents(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: K (locate on site plan)
Depth below�arac'te:
Material of construction: QLconcrete metal fiberglass___polyethylene
_other(explain
If tank is metal list age:— is age confirmed by a Certificate of Compliance(yes or no)-—(attach a copy of
certificate) /
Dimensions: PDOQ ?C 1
Sludge depth: 1
Distance from top of sludge to bottom of outlet tee or baffle- S Scum thickness: d 0
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scla rn to bottom of outlet tee or affle: k3
How were dimensions determined: )4 sv'O
Comments(on pumping recommendations,inlet and outiet tee or baffle condition,structural integrity,liquid levels
as relate o outlet invert,evidence of leak e,etc-): (�
i ' w%tMA
GREASE TRAP: (locate on site plan)
Depth below grade:
Material of construction: concrete metal Z
olyetlzylene—other
(explain)- — —
Dimensions:
Scum thickness:
Distance from top of scum to top of o tee or baffle:
Distance from bottom of scum to bo m of outlet tee or baaale:
Date of last pu±npi_ng:
Comments(on pumping reco endations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,ev" ence of leakage,etc.):
7
i
PWo�r=:
()FFICUL INSPECTION FORM—NOT FOR VOLLTNTA Y ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION ION(continued)
Property Address: �_�S'" 4?13;k(lip
Owner: ��o�� .s V 1
Bate of Inspection: t t
TIGHT or HOLDING'TANK: (tank must be p at time of inspe on)emcate on site )
Depth below grade:
Material of construction: concrete etas fiberglass polyethylene other(ex):
Dimensions:
Capacity: Ions
Design Flow: —._llons/day
Alann present des or no):
Alarm level: A in working order(yes or no):
Date of last pumping:
Comments(conditi -of alarm and float switches,etc.):
DI TRIB L''I'I€ N BOX: X (if present must be opened')(locate on site plan)
Depth of liquid level above outlet invert: e 0A
Comments(note if box is le-vTel and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.): ( f
i vt 100 k &J G.S f Ve t a_v C6.r tt j
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or �:.
Alarms in working order(yes no):
Comments(note condition pump chamber,condition of pumps and appurtenances,etc.):
g
page 9 Y#
OFFICE I SP �`70FORUM—NNOT FOR VOLUTNT ARY ASSESS t-TS
SL.TBSUkFA E SE4 A GI=DISPOSS S Y S'i E SPE ION FORIM
PART C
SYSTEM-1INFORMATION(continued)
Property Address: 6-- (it/�dC (f,m q
� viZl
Owner_
Date of Inspection:�
SOIL ABSORPTION SYSTEM (SAS): (locate on site plats,excavation not required;
if SAS not located explain why:
Type
leaching pits,number_
teaching chambers,number
teaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type,'name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc-): l'_
el, 2
CESSPOOLS: (cesspool must be pumped as part of inspection)(Iocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invent:
Depth of solids layer:
Depth of scum layer:
Dimensions 4ndition
Mate<^:als Of
Indication ow(yes or no)-.
Comments( il,signs of hydraulic failuree,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(mote c ivon Of soil,suns of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Per- l0 of 11
4F`F'ICiAL INSPECTION F ORI —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR
PART C
SYSTEM INFO ATIONT (continued)
Property Addrms:��� � �i;�C% 4e
Amer / fe- �—`--
Hate of ks on: �O
SKETCH OF SEWAGE DISPOSAL SYSTEM
:Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks_Locate all wells within 100 feet.Locate where public water supply enters the building.
J
I'
Page I¢ of*E 1
OF FICUL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS EI-t7S
SUAI SEWAGE SSVV 1�va
DAFT C
SYSTEM INFORMATION(continued)
I'r:,p2rtg Address: c 'f�' l 4 J
-e
Owner:
Date of Inspection: ,'Z�- 4�66-
SITE EXAM
Slope k*v Surface water O
Check cellar
Shallow wells OU0
Esti,.,ated depth to g ound watek>Z feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
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-howyou established the high watey eleva "on:
t> Q
11
TOWN OF BARNSTABLE
LOCATION 2 3 S &Je-yr WIAIV C R'. SEWAGE # 2ao2- 3 V O
VII:LAGE g' SSOR'S MAP & LOT - p<I 0
INSTALLER'S NAME&PHONE NO. ,T. 4A A C 0,1013 ed 't S GN
SEPTIC TANK CAPACITY / 0 60 - 0 [Z2
LEACHING FACILITY: (type) ul elL S (size) x
NO.OF BEDROOMS
BUELDER'OR OWNER ru
PERMUDATE: OMPLIANCE DATE: &/0
Separation Distance Between the: .
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
1
a �
l \ �
vur,s w;.-d C i r,
TOWN OF BARNSTABLE
LOCATIGi `�3 �f , 4 >i 6°. SEW _.. .
;ApGE�(#'
VILLAGE ,WX& APOW>'�. � � �1P°�`L'
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) ���
E
NO. OF BEDROOMS
BUILDER OR OWNER �G�®" .-
PERMITDATE: COMPLIANCE`DATE: _
Separation Distance Between the: t n
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 Le Piing Facility (If any wetlands exist
within = Fe ithin 3 fe f et
c f ili
tY)
Furnished y
i
� r
No. r FEE
$50. 00
0A�-COMMONWEA1TH,4,MAS4EffF§R
\T\
Board of Health, , MA. v
APPLICATION FOP, DISP®SEST5TA MON PERMIT
Application for a Permit to Construct( ) Repair4� Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components
Location235 West Wind Circle Owner's Name Murray M. Scott
Map/Parcel# Osterville ,Mass. / Address I0-5 'Valon'.;Dr ve-.Apt i6
Lot# 43 /21-011-042 Telephone#
MarlboroME—ss. 01 /52
Installer's NameJ.P.Macomber & Son Inc. Designer's Name Ronald J.Cadillac
AddressBox 66 Centerville Mass .02632
Addressp.O.Box 258 W.Y.Mass. 02673
Telephone# 508-775-3338 Telephone# 508-775-3338
Type of Building Lot Size sq.ft.
Dwelling-No.of Bedrooms 3 Garbage grindeNP)
Other-Type of Building No.of persons Showers ( ),Cafeteria ( )
Other Fixtures
Design Flow (min.required) 3 3 0 gpd Calculated design flow 3 X 1 10 Design flow provided 3 5 0 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Adding t p p e-Y i s t:p g b y s tomes 2—5 0 0 gallon
leaching chambers . 29 'X10'X10"x2 '
The undersigned agrees to' tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre to not to I tem pej Atdon until a Certificate of Compliance has been issued by the Board of Health.
Signed Date $ $ 2
Ins ,lions4,1"�2m"Jt� �✓
$50' 00
N
FEE o. ...
U\�
`-COMMONWEALTH E-N44AGW44�s
I '-Board of Health, �" �-r , MA.
APPLICATION FOR DISPOSAF-S--YSTEM CONSTRUCTION PERMIT
w ,
Application for a Permit to Construct( ) RepairT:j Upgrade( Abandon( - ❑Complete System ❑Individual Components
Location235 West Wind Circle Owner's Name Murray M. Scott
Map/Parcel# Osterville,Mass. / Address 2(35AVaAbnWbndv6iApte6
Lot# 43 t21-011-042 Telephone#
Marlboro Mass.01752
Installer's Name J.P.Macomber & Son Inc. `Designer's Name Ronald J.Cadillac
Address
Bo 66 Centerville ,Mass. 02632
AddressP•0.Box 258 W.Y.Mass.02673
Telephone# 508-775-3338 Telephone# 508-775-3338
`Type of Building Lot Size sq.ft.
Dwelling-No.of Bedrooms 3 Garbage grinde"A)
' Other-Type of Building No.of persons Showers ( ),Cafeteria ( )
Other Fixtures
Design Flow (min.required) 330 gpd Calculated design flow 3X 11 O Design flow provided 350 gpd
Plan: Date Number of sheets Z Revision Date
Title
Description of Soil(s) -
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Adding t g o A x i e t i n a §y s t a m. 2—5 0 0 gallon
leaching chambers. 29 'X10'X10"x2 '
The undersigned agrees to install the above desc ' ed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agreed to not toVlathe ystem < pe tion until a Certificate of Compliance has been issued by the Board of Health.
Signed ` Date 8 8, 02
0 c y
Ins ctions
No. r O FE�50.00
�. � COMMONWEALTH
Board of Health, Barnstable MA
CERTIFICATE OF COMPLIANCE
Description of Work: Undividual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( )
by: J.P.Macomber & Son Inc.
at 235 West Wind Circle Osterville,Hass.
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 J.P.Macomber & Son Inc.
Ronald J. Cadillac ,f f h �Designer: Inspector: � _ �� � Date:
CJ 4The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. e FE$50. 00
COMMO WLALT14 ®F MASSACHUSETTS
Barnstable
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair � Upgrade( ) Abandon( ) an individual sewage disposal system
at 235 West Wind Circle O s t e r v i l l e, a s. as described in the application for
Disposal System Construction Permit No. '-�.W)d
r
Provided: Construction shall be completed �t+hihthree years of the date of is m/i/t�f l local nditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston MA Date U V Board of Health r9 1 �
TOWN OF 13ARNSTABLE
LOCATION 3 S &I e s r SEWAGE #:I E - 3 V D
VILLAGE C e ti fP R L1 i L L e ASSESSOR'S MAP & LOTI—O .
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY / o is D - a 4 O
LEACHING FACILITY: (type) (size) 9pf Al/d
NO.OF BEDROOMS 2
BUILDER OR OWNER
PERMTTDATE: Fr S dX . COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom'of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
G
I
gV
s= O
00
G -
RMIT NO.
VILLAGE
.._ l;
INSTALLER'S NAWE A 0 0 A s5
GUILDER O:R, 'dWMER
e ei)4 k�s /?po
GATE PERMIT ISSUEO� ®�/�$
Jf
DATE COMPLIANCE ISSUED 10_3I-g5
..
�d q3
A `"1
JOB NO. B02-10
NOTES Scott.dwg
RTE 28
LO 1. LOCUS IS A.M. 121, PARCEL 11-42.
2. ELEVATIONS SHOWN ARE ASSIGNED. O
a 3. LOCUS IS IN FLOOD ZONE C ON FIRM DATED AUGUST 19, 1985. NOT TO °'
4. ALL PIPES TO BE 4" SCH 40, AND PITCHED AT 1/4" PER FOOT. (UNLESS NOTED) SCALE
0) 5. MUNICIPAL WATER IS AVAILABLE. LOTS WITHIN 100' ARE ON TOWN WATER. �Nr
N 6. COMPONENTS TO BE AASHTO H-10, UNLESS NOTED. o
m 7. INLET TEE TO PROJECT DOWN 13", OUTLET TEE DOWN 14". Cy
8. IF TWO OR MORE LINES, WATER TEST D-BOX FOR EQUAL FLOW .tied �•
D-BOX EXIT PIPES TO BE LEVEL FOR FIRST TWO FEET. `N
9. DEPTH OF COMPONENTS NOT TO EXCEED 3', OR VENTING MUST BE PROVIDED. o
BUILD UP COVERS TO WITHIN 1' OF GRADE. MORTAR CHIMNEYS IN PLACE.
BENCH MARK--N.W. CORN. CONC. ONE COVER OF TANK TO BE WITHIN 6" OF GRADE.
BULKHEAD = 38.87 ASSIGNED 10. STONE TO BE DOUBLE WASHED 3/4 TO 1 1/2" WITH 2" MIN. 1/8 TO 1/2" PEA STONE ON TOP. LOCATION MAP
11. IF UNSUITABLE SOILS, OR SOILS DIFFERING FROM THE SOIL LOG ARE FOUND,
N/F 26 CONTACT THE BOARD OF HEALTH, OR R.J. CADILLAC.
12. IF AN OVERDIG IS CALLED FOR BELOW, FILL MATERIAL FOR 5' AROUND AND UNDER LEACHING TEST HOLE 1
HUBBARD BENCH MARK--TOP OF WOOD IS TO BE CLEAN GRANULAR SAND MEETING SPECIFICATIONS OF 310 CMR 15.255(3).
STAKE= 36.34 ASSIGNED 13. PUMP AND FILL ANY EXISTING CESSPOOLS. REMOVE ANY CLOGGED SOIL, BLOCK, AND STONE IN DEPTH (inches) ELEV.(feet)
1_1 \ LEACH AREA, AND DISPOSE OF AS DIRECTED BY HEALTH AGENT.
14. ALL CONSTRUCTION TO MEET TITLE 5 AND LOCAL REGULATIONS. 0 38.8
29.4 2
3 REDUCE GRADE OVER UPHILL TEST HOLE DATE: June 24, 2002
PERFORMED BY: Ron Cadillac, Soil Evaluator Fill
36.4 4 SIDE OF LEACHING TO ELEVATION WITNESSED BY:
Ir tib ti 39.2 (3 COVER MAX.), AS SHOWN. PERC RATE: <2'-00"/inch (C layer)
N/F ' 39.51f SOIL SURVEY(1993): Carver coarse sand
�. GEOLOGIC MAP 1986 : Harwich outwash lain deposits 22" 36.9
PEARSON C �� 40. ,� 37:0 36 35.6 3� ��� EExist.
( ) P8
3 3 Invert 35.96 a
6, 35.3 2 DRY WELLS 40"
N/FUse Gas Baffle
5 Existing Invert 35.53 C layer 2.5y 6/4
1.4 Proposed
7.4 6.3445112' 33 FOX 36.2=Top Conc. medium sand
3 � Existing
S=1/4"/ft 35.85=Top Peastone
44 N
-,7 1000 Gal.37. _ _ _ _ -�
L 0 T 43 38 24" 126" no water 28.3
4 .
\, 36.3 I
45 6 I 11 / j� 2 8 Invert 35.70 Invert 35.35 33.35
I 6 Stone or compact Proposed Proposed 5 Bottom
I IN) I 8 I
15, 625± S. F TH 1 ° �-,� rn 8 Bottom TH1=28.3
38. �oJ o5��e 7 DESIGN DATA `�
4 .0 G 0
� 3 3.9 ; BEDROOMS: 3
�\ j1 GARBAGE GRINDER: No LEACH AREA
REQUIRED CAPACITY: 330 GPD
N/F ,� 37.7 ^gyp/ SEPTIC TANK: 1500 GAL. USE 2 DRY WELLS SET 6' APART WITH
N �o j' BOTTOM LEACHING AREA: 314.1SF 3' OF STONE ALL AROUND FORA 29'
DOBEM s� or O 7 8 [(29' X 10.83')] X 10'-10" X 2' DEEP LEACH AREA.
^64 d �p SIDE LEACHING AREA: 159.3 SF
a 'j h �g6 31 [2(10.83'+ 29') X 2' DEEP)]
38.9 3 37.81 0 tK l`�/
30'8� DESIGN CAPACITY: 350 GPD
4V N // . [(314.1 SF + 159.3 SF) X .74 GPD/SF]
37.4 \
GAS LINES NOT MARKED AT TIME OF FIELD
WORK, BUT ARE IN FRONT YARD. 33.5
,4
7
34.-
='4.c�
SITE PLAN
v�
FOR
THIS PLAN IS A VALID COPY ONLY IF IT BEARS
AN ORIGINAL RED STAMP AND SIGNATURE. MURRAY M . & FRANCES SCOTT
I"AOF gss9c �PL�N OF MISS LOT 43, 235 WEST WIND CIRCLE, OSTER VI LLE, MA
LEGEND o RONALD �� `'� RONALD 9cy�A S JU N E 249 2002 SCALE: 1 "=20'
C
T H '. TEST HOLE LOCATION, NUMBER CADI C � CA Cn
W WATER LINE MARKINGS PF, o 1T
c,is i Ep� C �ESS�O Q-
-E OVERHEAD ELECTRIC WIRES (IF SHOWN) s lN/S l� - gtio sS S\0
3.5 & EXISTING & PROPOSED ELEVATIONS ('X' MARKS POINT) i RONALD J. CADILLAC, PLS, RS
EXISTING CONTOUR C IC�Z PROFESSIONAL LAND SURVEYOR & REGISTERED SANITARIAN
8 PROPOSED CONTOUR P.O. BOX 258
0 UTILITY POLE (IF SHOWN)
® EXISTING DRAINAGE CATCH BASIN WEST YARMOUTH, MA 02673
X - FENCE (IF SHOWN, NOT ALL SHOWN) (508) 775-9700
HEALTH AGENT APPROVAL DATE
C 2002 BY R.J. CADILLAC PAGE 1 OF 1
e"�)'n/ - 6 ` 2