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HomeMy WebLinkAbout0141 WIANNO AVENUE UNIT #C - Health 141 Wianno Ave Osterville A= 140-054 r i 0 TOWN OF BARNSTABLE LOCATION 1 ( (/y(an no dy E#ri S/® VILLAGE ('S��(�V 1 ASSESSOR'S MAP&PARCEL job/�(�� fR S NAME&PHONE NO. t f tt)� O/I'�P.6 L l rr?_� SEPTIC TANK CAPACITY 00 LEACHING FACILITY:(type) d/1C1nht (size) NO.OF BEDROOMS S OWNER MOr;V-1 PERMIT DATE: -�DATE: rS P �3 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 ! ! ? ! I ? f /' i f ? r ? f I+ vJ f f f f r �•l f ? f ? f"! l L \ h ± \ h \ Y t \ h J t .\ t \ t \•t• h 'v h \ t. Y h \ Y. i l ? f 'f ?v. of •f f / .' f J f f J ! l ! f ! f ! - I f / f / ? f ? I ? l J ? i f f f / f J/#�}!'Y J f••��f++��,,l !t t \ Y \ \ Y '•. v \ \ t 'v t v t \ \ \ tRR�:r9.�h 42 1 t Y t \ \ Y t \ t t t t L k Y Y \ \ \ \ \ t \ t 13 34 � r TOWN Of-BARNSTABI:E LOCATION ' V/ k✓1, d-1-!.f) i/K SEWAGE # ;t VILLAGE S? , ` _ASSESSOR'S MAP & LOT/q 0 0SI INSTALLER'S NAME&PHONE NO. ® / SEPTIC TANK CAPACITY d LEACHING FACILITY: (type) �� (size) NO.OF BEDROOMS BUILDER OR OWNER ^ Jni 7 a PERMITDATE: COMPLIANCE DATE: . Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility _ ou 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 f, within 300 feet of leaching facility) Feet Furnished by _ AY� ✓ C1 - : .. �! 1� kA 1� t +t. s i TOWN OF BARNSTABLE G.J, eo/to CLf/ SEWAGE # VILLA JE O�S-�rr, 1�p ASSESSOR'S MAP & LOT Zk INSTALLER'S NAME&PHONE NO. Ca itd c3rlB r7�!7 C/ SEPTIC TANK CAPACITY �SoO LEACF JNG FACILITY (type) (sine) NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE:!Y-(/ 1 G.OMPLIANCE DATE: 5(2-Afh ry Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 '! �� �� I .,9 9 _ -- �9 '' 9., _� o f � � l I I! i _ __ .. �- �' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments 141 Wianno Ave — Property Address -^ John Morin — Owner Owner's Name information is Osterville MA 02655 March 13, 2012 required for 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 I._J1— vl forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'%on ieii — cursor-do not Name of Inspector use the return key, Septic Inspection Services Co. Company Name 189 Cammett Road — company Address Marstons Mills MA 02648 — rennn City/Town State Zip Code 508-428-1779 S1 12855 — Telephone Number License Number B. Certification 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 ❑ FMIS 8 - ❑ Needs Furth Evaluation by the Local Approving Authority f March 13, 2012 Job# 12-38 µ Ins ector's Signature Date The system inspector shall submit a copy of this inspection report to the Approvi tg Authority (Bo- of Health or DEP)within 30 days of completing this inspection. If the system is a shared system f?f, 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. (5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 v� Izz)I Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Wianno Ave — Property Address John Morin Owner Owner's Name information is Osterville MA 02655 March 13, 2012 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: Tank was not in need of pumping at time of inspection, leaching system showed no signs of saturation or surcharge 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Wianno Ave Property Address John Morin — Owner Owner's Name information is Osterville MA 02655 March 13, 2012 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 [I ND (Explain"below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a 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•11/10 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 141 Wianno Ave — Property Address John Morin — Owner Owner's Name information is Osterville MA 02655 March 13, 2012 required for — 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. r— - .,: i;,.. C/��� and h n r: ti' -a..nc 1-of,a r� 4hli� U ThE system has a-sepi:;c 1Gnlr and SAS and the Sr% fs.wit, in a Zfone. 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 El ® 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 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal!System Form -Not for Voluntary Assessments 141 Wianno Ave _ Property Address John Morin _ Owner Owner's Name information is required for Osterville MA 02655 March 13, 2012 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.port on of cesspool or privy is.✓✓ithin.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 11 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•11/10 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 141 Wianno Ave Property Address John Morin _ Owner Owner's Name information is required for Osterville MA 02655 March 13, 2012 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? ® ❑ 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 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): 5 Number of bedrooms (actual): 4 — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 — t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Wianno Ave _ Property Address John Morin _ Owner Owner's Name information is required for Osterville MA 02655 March 13, 2012 every page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: .4 — Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No N/AWater meter readings, if available last 2 ears usage d system. Irrigation g ( y g (9p ))� system. _ Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. _ Commercial/industrial Flow Conditions: 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? ❑ 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: l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Wianno Ave Property Address John Morin Owner Owner's Name information is required for Osterville MA 02655 March 13, 2012 every page. Cityfrown 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: None 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•11/10 B 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 141 Wianno Ave _ Property Address John Morin _ Owner Owner's Name information is required for Osterville MA 02655 March 13, 2012 - every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance date: 5/14/07 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): • 2, Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 16" _ 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: 10.5' long x 5.8'wide- 1500 gal._ 3„ Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Wianno Ave Property Address John Morin Owner Owner's Name information is required for Osterville MA 02655 March 13, 2012 every page. Cityfrown 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 29" — Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? 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.): Liquid level was found at bottom of outlet invert and tees were intact. Tank was not in need of pumping. 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-11110 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 � 141 Wianno Ave Property Address John Morin Owner Owner's Name information is required for Osterville MA 02655 March 13, 2012 — every page. City1rown 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 141 Wianno Ave Property Address John Morin Owner Owner's Name information is required for Osterville MA 02655 March 13, 2012 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): 01. Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No solids or higgh stains present, liquid level was at bottom of outlet pipes., 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•11/10 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 141 Wianno Ave Property Address John Morin Owner Owner's Name information is required for Osteryille MA 02655 March 13, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: — ® leaching chambers number: Four 500 gal drywells. ❑ 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.): Stone and soils surrounding SAS were probed with no evidence of saturation or surcharge found. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Wianno Ave Property Address John Morin Owner Owner's Name information is required for Osteryille MA 02655 March 13, 2012 _ every page. Cityrrown 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•11110 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1iI of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a . Subsurface Sewage Disposal System Form Not for Voluntary Assessments 141 Wianno Ave Property Address John Morin Owner Owner's Name information is required for Osterville MA 02655 March 13, 2012 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 building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately V 42 3 34 12/1 3 r4 X X Commonwealth of Massachusetts r Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 141 Wianno Ave Property Address John Morin Owner Owner's Name information is Osterville MA 02655 March 13, 2012 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 15+ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 5 and topo map shows property above el. 30. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 141 Wianno Ave Property Address John Morin Owner Owner's Name + information is Osterville MA 02655 March 13, 2012 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E check ed ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn,on page 15 or attached in separate file I l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 o'Lo o� �3 g S No. � • Fee 0 t TIE COMMONWEALTH OF MASSACHUSETTS ` Enured in computer: _ PUBLIC HEALTH Vy'VVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZppYicatiVu for �Digponl 6p5tem: Con0truction Permit iJ Application for a Permit to Construct( Repair O Upgrade O Abandon O omplete System ❑Individual Components Location Address or Lot No. / "` � �f j�< Owner's Name,Address,and Tel.No. /1YV Asses—sor's Map/Parcel e A �y Installer's Name,Address,and Tel.No. / 'r 0 170 So Designer's Name,Address and Tel.No. � - B Type of Building: Dwelling No.of Bedrooms Lot Size 23 / sq. ft. Garbage Grinder ( ) Other Type of Building S%o?A /4— No.of Persons Showers( ) Cafeteria( ) Other Fixtures �2 J Design Flow(min.required) //0 gpd Design flow provided 0 gpd Plan Date kh q 77 Number of sheets Revision Date Title .9�r�h rr Gyi-i� 1lr JC, "•�'(_' o^ Size of Septic Tank Z 4570 CD Tyope of S.A.S.( &L hrrj Description of Soil Xe c Ae,-A Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Heal Signed Date Application Approved by Date / &-?0' -7 Application Disapproved by: i Date for the following reasons Permit No. a-o 0 ,Date Issued " —0 �. y 00* No. •,, Fee ...>Et red in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS i ZlOpfica�tion for• gpogal �bpztem Cone truction Permit K Application for a Permit to Construct Repair O Upgrade(`) Abandon O /Complete System ❑Individual Components Location Address or Lot No. /C�/� �v= Owner's Name,Address,and Tel. o. /y/ �/�h/7Q d 2, � IGZs9>'!C1 Assessor's Map/Parcel IInstaller's Name,Address,and Tel.No. �U �d. �V Designer's Name,Address and Tel.No� _ n�( �Ni'i� �%,-,cl,,t�i�� �--�•/�I.PAc/!�r• �' ,pv�/t ��^G`�tee.-��l f�� `'�.• l O 1S a�Z S x 1� /Ow GJ f Type of Building: j j Dwelling No.of Bedrooms Lot Size 73 rvV sq.ft. Garbage Grinder ( ) Other T e of Buildm t yp g .SI/� �i+7' No.of Persons Showers( ) Cafeteria( ) Other Fixtures �j . .4,M -1- .� Design Flow(min.required) //0 gpd Design g flow provided gpd S � �.) Plan Date �\h 7 t( Number of sheets / Revision Date --� Title T ti r. os rr,1 xfll�cle-1-�. /��O!i ✓' Size of Septic Tank / 70 CD Type of S.A.S.0 y) ,�y a / ("-47Ar,.,`je,j Description of Soil X-r-e /„!.f v dC 5nC±rrrZ1, '17 �s� /) 1 5 �e Nature of Repairs or Alterations(Answer when applicable) j Date last inspected: I e Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healtlr Signed �i�,.! Date Application Approved by `C 1 . Date -7 t Application Disapproved b : Date PP PP Y e a for the following reasons Permit No. U 7 Date Issued �/ 'G` C' ` —— ——————— ———-——— ————— ——— ——— ——-- THE COMMONWEALTH OF MASSACHUSETTS I BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded Abandoned( )by oe at L..I , e rT�-��/ ��1 _ has been constructed in accordance � U with the provisions of Title 5 and the for Dis osaI System Construction Permit No. o U 3 7 dated Installer_,�aP-f-'-, �n Z (` ci/eJ Designer #bedrooms _.�"r- Approved desygn flow C gpd I The issuance of thi permit shall not be construed as a guarantee that the system will function/as designed Date Inspector �(/ h• Ste" - --------------- ---------- -- ---—------------ No. U 0 7 - -2 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS wigoml *pztem Con6truction J)ermit Permission is hereby granted to Construct ( Repair ( ) Upgrade ( ) Abandon ( ) System located at a ,�20-7 rs 4!e - i i and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Q Date Approved by 4 Town of Barnstable Regulatory Services Thomas F..Geiler,.Director BAR,\STABLE. 9 MASS. $ Poblic Health Division s6gq. ♦0 Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 8 Sewage Permit# Z04-7-3 3 7 Assessor'sMap\Parcel Designer: 'J, DOYLL- '45-50C1,4 i-6 5 Installer: Lr/fez( Address: l 7d CLo L,,6 WX y Address: �_D 7 /�1!TCI�I�/G L /�•J OZS36 (.v GfGf/�2NST�IBL C—� /!�I<9. OZ a., On / 07 Ali'ZdWt-I was issued a permit to install a (date) (installer) septic system at f /yVE based on a design drawn by (address) .% D6YLt, ASS06-1A7L s dated hV&-. 13 , Z0a7 (designer) / certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local ons. Plan revision or certified as-built by designer to follow. �pA OF Nt�S`�9c o� ARE sG A R N (Insta er's Signature) 1 =1'1 0 I S T.c t+�o 1 s'4MItARk Q 2� Ob V esigner's Sign tBARNST (Affix Designer's Stamp Here) PLEASE RETURN TO rBLEUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DMSION. THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.doc Y� If NN raj •�� �i—y- - ( �� � '�� 3 f �'— a�ai\\� ' 14 rx �� 11 } _\ t If C� A 3 1 1 S rl Fi {{ f W f . II !I - _.�• — I�•�-- ". t'; ; I j � � Ali ' ! s; 11, -, _ ®c. . 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