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HomeMy WebLinkAbout0204 WIANNO CIRCLE - Health j 2D4 Wianno _ `' . OStervil lG- ! y 140 108: fit. �I i I I TOWN OF BARNSTABLE LOCATION nL WV C 0C,1, 'SEWAGE �f VILLAGE 0- ASSESSOR'S MAP&PARCEL&a�/D _ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) A eAatl<rA46 ,<size) AJ,dV yG y7J,2> NO.OF BEDROOMS OWNER PERMIT DATE: 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) n Feet FURNISHED BY I ' 6 b W r � TOWN OF BARNSTABLE LOCATION 0- 0y C,s�`.ar,;n,,^ , C_; `g. SEWAGE# NhLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SE'PTle-T*NK CAPACITY LEACHING FACILITY:(type)Jam: (size) qCZ-) CA,&, NO.OF BEDROOMS OWNER S-Tr3, ck^ PERMIT DATE: 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 �� 30� TOWN OF BARNSTABLE, LOCATION W jAM 0 Clydk SEWAGE # VILLAGE 05rtrVJLL ASSESSORS MAP & LOT INSTALLER'S NAME&PHONE NO., SEPTIC TANK CAPACITY asspca) LEACHING FACILITY; (type) al (size) NO.OF BEDROOMS BUILDER OR.OWNER bie. S PERMITDATE: COMPLIANCE DATE: 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 leachi g facility),_ l Feet Furnished by Srl S J rol G A a C3 1 136 33 --------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CE that the On-site Sewa a Dis o 1 System Constructed( )Repaired( )Upgraded( ) Abandoned y at h bee constructed i accor ance with the prr�viis�'ons of Title 5 and for D,is* System/ nstruction Permit No. p 1 "� d �� Installer Designer a The issuance of this permit shall not be construed as a guarantee that the sy m w*11 function as designed. r Date — "— Inspector E No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for Mt000al *pgtem Congtructton Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. do w/ !v l : Owner's Name,Address and Tel.No. 13 leeS�-/fin! Assessor's Map/Parcel � Installer's Name,Address,and Tel.No. ' 'p / Designer's ame,Address aDd Tel.No. � 1 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow `"L o gallons per day. Calculated daily flow `7 D gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /:� Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when ap licable) Date last inspected: Agreement: -� The undersigned agrees to ensure the constructiotalth. ntenance o t e afore described on-site sewage disposal system in accordance with the provisions ab of a Envia de of to place the system in operation until a Certifi- cate of Compliance has been iss d o H � /l Signed Date U Application Approved by Date Application Disapproved for the fol ing reasons Permit No. Date Issued No. Fee (/ — f 1 2 ' Entered in computer: `C THE COMMONWEALTH OFo MASSACHUSETTl t S Yes PUBLIC HEALTH DIVISION TOWN OF BARNSTABLES MASSACHUSETTS Z(pprication for Miopogal *pgtem Construction Permit . Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 4�w WI J V!V O O r Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. C.< `��q Designer's Name,Address d Tel.No, •S Q• -7-j3 i�J4M eOAJ 6 ,PVC. a,5-6^0coqvG� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ), Other Type of Building / of Persons Showers(' ) Cafeteria( ) Other Fixtures //' � ��/ f Design Flow `7 gallons per day. Calculated daily flow `7`�� gallons. Plan Date /. Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: a The undersigned agrees to ensure the construction and maintenance o t e afore described on-site sewage disposal system in accordance with the provisionsGb 5 of iae Enviroo ineaddrU,de a of to place the system in operation until a Certifi- cate of Compliance has been is s o of Health. Signed _ c- Date 3d l Application Approved by Date Application Disapproved for the following reasons t 1 M. Permit No.' Date Issued 1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that t.een On-site xzms� l System Constructed( )Repaired( )Upgraded( ) _ Abandoned ) y �C/� //C at 0`7 I? 1\10 �h/as been,- constructed in.a ordance with the pr�°..))visions of Title 5 andy�four Dis os 1 System Construction Permit No y'�,t�l d �' Installer NKYYI � f 1��'Jl� i A/C- Designer The issuance of this permit shall not be construed as a guarantee that the s s``t�in will functio a desi ned. l Date P g Inspector y �a - ( ` No. C�l�! —————————--Fee - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Zfi6pozal *p.5tem Construction Permit Permission is hereby granted to Construct( )Repair( )U grade(%o )Aba don( ) System located at .+��� � t_ and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Constructioq musl be completed within three years of the date of this peerrmi_it. Date: �7 f . �(> Approved by / 9-6 bd ;No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS r� ZIppCication for 30iopozal Opotem Construction Permit Application fo Met to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 070q W11 Qnno Cp r-C q— Ow er's ame,Address and Tel.No. 80 a n 5l DS-i�vQ I le raft I��c�►a rd �(�to-ran Assessor'sMap/Parcel P-Vq W Q/)no 0i^Cf e •l Ins F s Namey kddress,and T 1.No. Designer's N e,Add ss and Tel.�j o. �JYl 1 O/I'�"i�C1.� CS M,3 ���. e LA vl �� p ( ��-(.�Je F�I �'`f--h !'. � 4 Type of Building: Dwelling No.of Bedrooms T Lot Size sq.ft. Garbage Grinder(M Other Type of Building kQU-Pi No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow `'f gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S�Pf a n Nature of Repairs or Alterations(Answer when applicable) ��� �i �-aPp r PIQ n-�s 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 provisio of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has be a h. Signed r Date Application Approved by Date �- Application Disapproved for the following ons Permit No. Date Issued dWN THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS. Certificate of Compliance THIS IS TO CE �at t e On- ite Sewage Disposal S stem Constructed( LRepaired(UpgradedAbandoned( )by C_ at 13 0 has been constructed in accordance with the proyyip�ts p ' tle 5 and the for Disposal System Construction Permit No. d2L�=_= Installer (�f -'1'�� Designer — The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector bd 17 0.# - ` d Fee THE COMMONWEALTH OF MASSACHU. TTS Entered in computer: Ye PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Miopozal ztem' Conotruction Permit Application for a)err t to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 0? (,v (�nA 0 C o r�I Ow er's Name,Address and Tel.No. F. OC�rU°I le r n it �i c hG�► � S Ha r-ran Assessor's Map/Parcel P y Lt'I Q n n 0 t�✓GI Installe 's Name,Address,and Tel.No. �-� Designer's Name,Address and Tel. o. i r�, r P � �n+rac-�-vou' oC.. �J -?;E, hanc�ers_ 3 3 H o lC.0 M'in j jzM4aL> U l ' 5`�- r7 3 1 -;Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(M Other Type of Building J±QU,5e e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Ty Design Flow 1'0 gallons per day. Calc^ulated daily flow 0 �"1 V gallons. Plan Date o�G, Number of sheets o� Revision Date > e Title Size of Septic Tank / 46 Type of S.A.S. - ` 'Description of Soil; Pin n Nature of Repairs or Alterations(Answer when applicable) Mena -S?Q FJn10S Date last inspected: � t Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisioN of Title 5 of the'Erivironmental Code and not to place the system in operation until a Certifi- cate of Compliance has be("* e �MVIR/, Signed -�--�" Date Application Approved by '°! Date L 'K-- ' Application Disapproved for the following re ons Permit No M� 17U Date Issued 1 dJq � . _- THE COMMONWEALTH OF MASSACHUSETTS - BARNSTABLE, MASSACHUSETTS , Certificate of Compliance THIS IS TO CEP3Wat t e On-site Sewage Disposal System Constructed structed( Repaired(�Upgraded( ) Abandoned( )by n "�-- at 3 13 HD n'l. C,._'[O&& E&31— r r Y has been constructed in accordance r with the proP ions Title 5 and the for Disposal System Construction Permit No. dated Installer ) �" I Designer I-Oo e'r's - The issuance of this permit shall not be construed as a guarantee that the system will function as designed. v Date Inspector No.ao ( ' V Fee �V V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS Mi!6po.5a1 *pgtem Conttruction Permit Permission is hereby granted to Cons ct )Repair( )Upgrade( )Abandon( ) System located at 0 n C. and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this Date: �l`�y Approved by �,�.�._` �` ��' I It - TOWN OF BARNSTABLE BOARD OF HEALTH ?'f ' ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION" ' Date r r "' Time: In Out Owner ~Tenant StAh'Iwl � It—S P � RR t7, Address ,W I DEC K- Q D Address -20q 1 A PJA Cl 94 L.e w Compliance Remarks or Regulation# --Ye;7 NO Recommendations 2. Kitchen Facilities 2 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities / 8.Ventilation ✓ 9. Installation and Maintenance of Facilities 10. Curtailment of Service I 11. Space and Use V 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal V 17.Temporary Housing 18. Driveway Width V/- 19. Number of Tenants Observed �( PART II 37. Placarding of Condemned Dwelling; 'Removal of Occupants; D�ermolition Number of Bedrooms' `[ Number of Vehicles Allowed (max) Number of Persons Allowed (max)Person(s) Interviewed btwL p, Rep Inspector If Public Building such as Store or Hotel/Motel specify here I Town of Barnstable t"E Regulatory Services g r3' Thomas F. Geiler, Director 9B MASS. Public Health Division rec rn0'�90. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: o Ig i� Sewage Permit# 2�1 -�"�� Assessor's MaplParcel J40-dog Designer: C_ e-Acim-th-e,�ft. Ls +� ��. Installer: _ IO X 6��-dAzn � Address: r q j3 WtW hcAnA 1410y Address: :31; A'k-,M &/0-3_ is S5fi 1%,aZASIVY 1A4 On i",km was issued a permit to install a (date (installer) septic system at kYAMU0 1 based on a design drawn by (address) ( ,n Oy -c4vi,tx dated �6/i 3 (designer) �cerdf�y hat 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 mayor. changes (i.e. greater than 10' lateral relocati o the SAS or any vertical relocation of any component of the septic system)but in a cord ce with State & Local Regulations. Plan revision or certified as-built by designer o follow. OF JOHN LANDERS-GAULEY (Installer's Si e) civil CIO a No.35101 f GISTER� ss/NNAL (D signe ' ignature) (Affix Designer's Stamp Here) PL SE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.doc Town of Barnstable P# #06 a� ►aa Department of Regulatory Services • ', � R/�" � wll..J� .uwST,.s,: Public Health Division Date' MASS. p 1639. �B• 200 Main Street,Hyarmis MA 02601 wa' Date Scheduled Time Fee Pd. 4.1 itab' �4'ssessm ht or Sew a Disposal � f .� Performed By: Witnessed By: LOCATION&'GENERAL INFORMATION' Location Address .. Owner's Name . 20y WIArJNp C//2CCE %fIC/lf7RD FSNARDAI l3.eIAAJ 6 57Ee V I L L EI Af A 016S`-T Address t�A 1<-oPA-/A 2 D, C Assessor's Map/Parcel: - Engineer's Name /M A oz46o NEW CONSTRUCTION REPAIR ' - Telephone# �N OEa 5 oe7L 3 _ Land Use _ Slopes(%) . Surface Stones r Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) ` t 'M r:�• Parent material(geologic) Depth to Bedrock Depth to Groundwater:-Standing Water in Hole: � Weeping from Pit Face IM*.� y�^•� - Estimated Seasonal High Groundwater DETERMINATIONA SEASONAL HIGH WATER TABLE' Method Used: - Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: - - in: Groundwater Adjustment ft. Index Well# Reading Date: Index Well level,. Adj.factor n' Adj.Groundwater Level_ - PERCOLATION TEST Date Observation • . .. .. _. Hole# Time at 9" - Depth of Pere Time at 6" ' Start Pre-soak Time @ Time(9"-C') End Pre-soak ` - Rate Min./Inch - - t Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original:Public Health Division Observation Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. ti l Q:\SEPTTC\PERCFORM.DOC I .VAE Town of Barnstable ra y� Department of Regulatory Services 4n - p3 Public Health Division Date •6�q.'�B' 20o Main Street,Hyannis MA 026 11 Date Scheduled Time Fee Pd. � itab' A'ssessm nt or Sew a Dis oral Performed By: W sad^By: w,. �1 LOCATION A GENERAL:I_NFORMATION - Location Address Owner's Name ... 20`r w1Ar4f4O C I AC CC icIc11,4le.D syAR&J 3,e;A1J5K aS7EreV/LZ_EI -Af.A 026SS _ Address zrp lcoDAyA 2v, Assessor's Map/Parcel: ,. Engineer's Name L-1 A,5 A 4 M A 02469 - 3FFCK �/#Nb"IeS- 6A-LEY NEW CONSTRUCTION REpppt Telephone# Sap- .,�Jr O , 7 3 _ Land Use 7e_t.J Uk1 0,,t` Slopes(%) 0':J _ Surface Stones Distances from: Open Water Body rl ft Possible Wet Area R Drinking Water Well - Drainage Way to R Property Line ft Other R - " r _ ` SKETCH:(Street name,dimensions of lot,exact locations of test holes Bc pert tests,locate wetlands in proximity to holes) 4D 'El " Parent material(geologic)__ I - Depth to Bedrock I Q, " ,_.I •` ' Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face - 1.4 .S IM41 c cfic• Estimated Seasonal High Groundwater DETERMINATION:FOR SEASONAL HIGH WATER TABLE_ �(* ...: _ I �, Method Used: - .. tx�t n -• Depth Observed standing in in. Depth to soil mottles: 60 A OL ' Depth to weeping t of obs.hole: in. Groundwater Adjustment ft. - Index Well# Reffiling Date: - Index Well level oun water Level k .:<'PERCOLATION TEST Date: Time Observation t Hole# Time at9" - y �4 ; ' Depth of Perc Time at6"` Start Presoak Time® Time Q � - - me(9"-6") End Presoak 4 —VbOS Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) " Original:Public Health Division Observation Hole Data To Be Completed on Back-- ***If percolation test is to be conducted within 100'of wetland,you must first notify the Barnstable Conservation Divilion at least one(1)week prior to beginning. .Q:ISEPTICIPERCFORM.DOC - ` .. + .. a •'4 DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon' Soil Texture Soil Color Soil Other . L Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. •• Consistency.%Gravel) Plw zz i /cA a r4 Q Tcx4�� I G1g2_ _ r 4 1U.- cZ �-¢ SW 10 i& DEEP OBSERVATION:HOLE LOG Hole# -Z Depth from Soil Horizon't Soil Texture Soil Color, Soil Other Surface(in.)• (USDA) (Munsell) ;Mottling. (Structure,Stones,Boulders. Consistency.%Gravel) 41 DEEP OBSERVATION HOLE LOG."- :. Hole Depth from Soil Horizon" - Soil Texture Soil Color Soil`` Other - - Surface(io.) - (USDA) (Munsell) Mottling (Structure,Stones,Boulders. - Consistency.%Gravell - DEEP OBSERVATION ROLE LUG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil. Other Surface(in.) ` (USDA) (Munsell) Mottling (Structure,Stones,Boulders. - sf ` - Consistencv.%Gravel) * Flood Insurance Rate Map: - Above 500 year flood boundary No— Yes— ' "i Within 500 year boundary No Yes Within 100 year flood boundary No Yes_ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? ' If not,what is the depth of naturally occurring pery us material? , Certification O I certify that on (date)I have,passed the soil evaluator examination approved by the "Department of Environmental Protection and that the above analysis was performed by me consistent with the required training,exp a and exp nee'described in 310 CMR 15.017. ,. Signature Date_ 1 "Ali Q:ISEPnC1PERCFORM.DOC z r ' r Vic. S �f TQ oll ! L� U1,13 JUL 22 74 •wg Ab- r `� '� � ► �6�� U � 72 IJ y EXIST. SUNROOM ra X � Al �I V 3 EXIST.. EXIST. DINING NEWDOOR KITCHEN 1 EXIST. GARAGE EXIST. ` .. HALL.• _- -- D BATH ra e EXIST. To au t LIVING CLOS4 �� EXIST. EXIST. "P FIRST FLOOR PLAN clot' Los. LEGEND: 0 EXISTING WALLS C= CONSTRUCTION TO BE REMOVED . ® NEW CONSTRUCTION f0 VERIFY ALL EXISTING CONDITIONS THE FIELD 3" VERIFY ALL INTERIOR 6 EXTERIOR MATERIALS, iES IN THE FIELD WITH OWNER DN TO CONFORM TO 780 CMR MASSACHUSETTS RODE STH EDITION AMENDMENTS&IRC2009 IBING 3 ELECTRICAL DETAILS W/OWNERS ON //p I FRAMING CONSTRUCTION o COTUiT BAY DESIGN, LLc NEW ADDITION/REMODELING FOR: S E: DRAWING NO..- Tom\gMWNL IIIIOIIA f0YR0 43 BREWSTER ROAD `��" "�""�°�""""` V-0" YIIL�LOOII�tI'CRMGGMMf BRIANSKY RESIDENCE M �MASHPEE MA. 02649 �� �'� PH.(508 234-1166 �M .DATE FAX(508)539-9402 204 WIANNO CIRCLE OSTERVILLE, MA 3r2n013 Al. m�urern�000a�uoatH - W4r /l/ew �kS � �/rr►'If/I �l�.S`?�/1'? l�iIIS`!i/ln I� l6x7bl� eve 1 A ffFM FAN � T PTO ovrs m O b a �O�./etiopc`, K �1 cvS/.76I/,o!?eo�o cLo MOD. 'y�WCL BATH :BATH EXIST. O t � BEDROOM �oow EXIST. oa(f A � III r-r oN. CLO$. EXIST. EXIST. BEDROOM BEDROOM Lill SECOND FLOOR PLAN COTUIT BAY DESIGN. LLQJ NEW ADDITION/REMODELING FOR " SCALE: DRAlk APW&.: 43 BREW$TER ROAD ^,� '" 1/4"=1'-0" .1,11R o..uno.•W.f1.LTpl Commonwealth of Massachusetts co?' Y' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Stephen Cochran Owner Owner's Name information is Osterville required for MA 02655 August 10, 2012 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form.. Important: A. General Information When filling out forms the 2 computer,use 1. Inspector: J only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter Excavating Company Name P.O. Box 89 Company Address Forestdale MA 02644 Cityrrown State Zip Code 508-888-6055 SI 12843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of.on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 16.000).The system: ® Passes ❑' Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority August 16, 2012 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 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. Urc �2 t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 1. r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Stephen Cochran Owner Owner's Name information is Osterville _MA 02655 • August 10, 2012 f required for _g 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: 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 ov/(Explain old* o the septic tank(whether metal or not) is structurally unsound, exhibits snfiltr Ion or exfiltration or tank failure is imminent. System . will pass inspection if the existiep ced with a complying septic tank as approved by the Board of Health. , *A metal septic tank will pass if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the than 20 years old is available., ❑ Y ❑ N ❑ ain below): t5ins•11110- Tdie 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Stephen Cochran Owner Owner's Name information is Osterville MA 02655 Au ust 10, 2012 required for g every page. City/Town State Zip Code pate 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ 'ND (Explain below); ❑ distribution box is levele r replaced ❑ Y ❑ N ❑ _ND (Explain below): L ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will ass inspection if with approval of the Board of Health): Y P P ( PP ) ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y' . ❑ N ❑ ND (Explain below): ` C) Further Evaluation is Re ired by the Board of Health: ❑ Conditions exist which r uire further evaluation by the Board of Health in order to determine if the system is failing to rotect public health, safety or the environment. 1. System will pas 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.f 1ryp Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rt 204 Wianno Circle Property Address Stephen Cochran Owner Owner's Name r f urired formation Osterville MA 02655 August 10, 2012 every page. City/Town state Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank a SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic t k and SAS and the SAS is within 50 feet of a private water, supply well. ❑ The system has a septic tank d SAS and the SAS is less than 100 feet but 50 feet or more from a private water su ply well". Method used to determine stance: This system passes if t e 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. r 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 El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool } ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6° below invert or available volume is less than '/2 day flow t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '( 204 Wianno Circle Property Address Stephen Cochran Owner Owners Name information is required for Osterville MA 02655 August 10, 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 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.,• El ® 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 00 feet of a surface drinking water supply ❑ ❑ the system is wit n 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is I ted in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA or a mapped Zone II of a public water supply well If you have answered "yes"to an question in Section E the system is considered a significant threat, or answered "yes" in Section D bove the large system has failed. The owner or operator of any large system considered a signifca threat under Section E or failed under Section D shall upgrade the system in accordance with 3 CMR 15.304. The system owner should contact the appropriate regional office of the Department. (Sins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Stephen Cochran Owner Owner's Name information is Osterville required for MA 02655 August 10, 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 ❑ ® 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 breakout? ® ❑ 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. ® a 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t 440 GPD ta`ins•11/10. Title 5 Official Inspection Form:Subsurface Sewage Disposal pecti g System-Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Stephen Cochran Owner Owner's Name information is Osterville MA 02655 August 10 2012 required for 9 every page. City/Town State Zip Code Date of Inspection D. System Information - , Description: Number of current residents: 6 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 Water meter readings, if available last 2 ears usage 2011=200 GPD g ( y g (gl�))' 2011= 200 GPD Detail: j Recommend removal of garbage disposal or pump primary yearly. High water usage in summer months only due to irrigation. Property is seasonal. Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: k Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., c.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank presen . r ❑ Yes ❑ No. Non-sanitary waste discharged t he Title 5 system? ❑ Yes ❑ No Water meter readings, if available: tSins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Stephen Cochran Owner Owner's Name information is g required for Osterville MA 02655 August 10, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No records found 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/Altemative 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): Converted cesspool and overflow cesspool t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 8 I - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle k Property Address Stephen Cochran Owner Owner's Name informaon requiredtiforls Osterville MA 02655 August 10, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed (if known) and source of information: Home built in 1971. No records on system at Bourd of Health other than previous Title V Report (2009) Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): " Depth below grade: 2.5feet Material of construction: ❑ cast iron ❑ 40 PVC Orangeburg ® other(explain): ' Distance from private water supply well or suction line'. N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good flow from sewer line at time of inspection. Recommend checking flow every year due to age of line. Septic Tank (locate on site plan)- 4" C.��,�Vc,r Depth below grade.- feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Converted Cesspool acting as septic tank. Concrete block. If tank is'metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 4'W X 6'D 6„ •s Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 d 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Stephen Cochran Owner Owner's Name information for required Osterville MA 02655 August 10, 2012 every page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Septic Tank (cunt.) Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 2" w Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Tape measure and dip tube. 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 orangeburg tees in place. Liquid level at outlet invert at time of inspection. No sign of high water staining over outlet invert. Recommend checking orangburg tees every year. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Stephen Cochran Owner Owner's Name information is Osterville required for - MA 02655 August 10, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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: f Capacity: • gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No a 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-11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Stephen Cochran Owner Owner's Name information is OStervllle required for MA 02655 August 10, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) . t Distribution Box (if present must be opened) (locate on site plan): 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamb r, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: tSins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Stephen Cochran Owner Owner's Name information is g required for Ostefville MA 02655 August 10, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches numberi length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1-4.5'W X 5'D ❑ 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.): Concrete bolck overflow empty w/damp base at time of inspection. High water staining 3"above base of overflow. No sign of past hydraulic failure. Hand auger 2+-' below base of overflow found no ground water.Access cover within 6" of grade. •r . 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 Forth:subsurface Sewage Disposal System•Page 13 of 13 f Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Stephen Cochran Owner Owner's Name information is required for Osterville MA 02655 August 10, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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 draulic failure, level of ponding, condition of vegetation, etc.): t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 204 wanno Circle Property Address Stephen Cochran Owner Owner's Name r�0�0n is equired for Osterville MA 02655 August 10, 2012 every page- City/rown State Zip Code Date of Inspection D. System Information (cunt.) 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 I Isrks•-11/to Tile 5 OftW b specbon Farm:Subsaafaoe Sewaga Disposal 9ys>tsm•Page 15 Of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •�y 204 Wianno Circle Property Address Stephen Cochran Owner Owner's Name information is .OSterville required for MA 02655 August 10, 2012 every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D.(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewag e ge Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Formci COPY Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Stephen Cockran Owner Owner's Name information is required for Osterville MA 02655 February18 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. Important::When filling out A. General Information - forms on the computer, use 1. Inspector: only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name PO Box 371 -17 Jan Sebastian Dr. Company Address i r Sandwich MA 02563 B°A City/Town State r Zip Code 508-888-2805 S112843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails r ❑ Needs Further Evaluation by the Local Approving Authority February 27, 2009 Inspector's Signature a 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. 204wiannocir-03/08 Title 5 Official Inspection Form:Subsurface S age Disposal System-Page 1 of 1 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 204 Wianno Circle Property Address Sephen Cockran Owner Owner's Name information is ry Osterville MA 02655 February 18 2009 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: ® 1 have not found any information which indicates that any of the failure criteria described' in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are ' indicated below. Comments: Garbage disposal needs to be removed. Not recommended for cesspool system. B) System Conditionally Passes: ❑ One or more system components as describtd 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. Answer yes, no or not determined (Y, N;ND) in the❑ for the following statements. If"not determined," please explain. }`$ ❑ The septic tank is metal andFover 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 tpnk will pass inspection if it is structurally sound, not leaking and.ifJa Certificate of Compliance jridicating that the tank is less.than 20 years old is available. ND Explain: 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 ❑. obstruction is removed 204wiannocir•03/08 • ' Title SOfficial Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Sephen Cockran Owner Owner's Name information is required for Cisterville MA 02655 February 18, 2009 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled;o replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pas§,inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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: 1. ❑ 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 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: i �3' ❑ 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 ha a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 204wiannocir•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Sephen Cockran Owner Owner's Name information is Osterville MA 02655 February 18 2009 required for rY every page. City/Town State 'Zip Code Date of Inspection B. Certification (cont.) , C) Further Evaluation is Required by the Board of Health (cont.) ❑ The system has a septic tank and SAS and th SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: r' 4 s r **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the pre'sence 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: i r 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 ❑ z 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 ❑ ® 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. 204wiannocir•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 204 Wianno Circle Property Address Sephen Cockran Owner Owner's Name information is Osterville MA 02655 February 18 2009 required for rY every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® 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 f ❑ ❑ the system is within 4,00 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)r or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D,above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 346 CMR 15.304. The system owner should contact the appropriate regional office of the Department. fi 204wiannocir•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 Wianno Circle Property Address Sephen Cockran Owner Owner's Name information is Osterville MA 02655 February 18 2009 required for ry every page. Cityfrown 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 ❑ ® 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)] s . 204wiannocir•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 f Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Sephen Cockran Owner Owner's Name information is Osterville MA 02655 February 18 2009 required for rY every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD Number of current residents: 0 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 Seasonaluse? ® Yes ❑ No Water meter readings, if available(last 2 years usage (gpd)): 200 =2 GPD 2008=208 GPD Sump pump? ❑ Yes ❑ No Last date of occupancy: September.08 Date Commercial/Industrial Flow Conditions: r Type of Establishment: Design flow(based on 310 CMR 15.203), Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.) � t Grease trap present? / ❑ Yes ❑ No Industrial waste holding tank present? ,f� ❑ Yes ❑ No Non-sanitary waste discharged to,thh/Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last-date of occupancy/use: Date Other(describe): 204wiannocir-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 204 Wianno Circle Property Address Sephen Cockran Owner Owner's Name information is required for Osterville MA 02655 February18, 2009 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: No records found 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): Converted cesspool with overflow cesspool. Approximate age of all components,date installed (if known) and source of information: House built in 1971. Only records availible at Town Hall. Were sewage odors detected when arriving at the site? ❑ Yes ® No 204wiannocir•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Sephen Cockran Owner Owner's Name information is required for Osterville MA 02655 February 18, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2'6"feet Material of construction: ❑ cast iron ❑40 PVC Orangeburg ® 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): 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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? 204wiannocir•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 204 Wianno Circle Property Address Sephen Cockran Owner Owner's Name information is Osterville MA 02655 February 18 2009 required for , every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): . 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 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 Elpolyethylene ❑ other(explain): 204wiannocir•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page.10 of 10 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 204 Wianno Circle Property Address Sephen Cockran Owner Owner's Name information is Osteryille MA 02655 February 18 2009 required for ry , every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: f gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: at'ry Alarm in working order: ❑ Yes ❑ No Date of last pumping: `° Date r Comments (condit on of alarm and float switches, etc.): / *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert r' 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.): Pump Chamber(locate on site plan): Pumps in working order: ,' ❑ Yes ❑ No Alarms in working order: , : ❑ Yes ❑ No 204wiannocir-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 11 l Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 204 Wianno Circle Property Address Sephen Cockran Owner Owner's Name information is required for Osteryille MA 02655 February 18, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ❑ leaching pits number: ❑ leaching chambers number: . ❑ leaching galleries number: ❑ leaching trenches number, 'length: ❑ leaching fields number, dimensions: ® _- overflow cesspool number: 1 -4.5X5 S ❑ 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.): Overflow cesspool dry at time of inspection. Concrete blocks are free of staining.No sign of past ' hydraulic failure. x 204wiannocir•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 204 Wianno Circle Property Address Sephen Cockran Owner Owner's Name information is ry Osterville MA 02655 February 18 2009 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) fir.;,-,.,,r�-.><•:-��-�. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1 Depth—top of liquid to inlet invert Dry 5' from invert to base Depth of solids layer 0 Depth of scum layer 0 Dimensions of cesspool 4'X 6'' Materials of construction Concrete block Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Converted cesspool dry at time of inspection. Outlet tee is oran ebur . Cover is 4" below grade. 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.): t� la 204wiannocir•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 204 Wianno Circle Property Address Sephen Cockran Owner Owner's Name information is Osterville MA 02655 February 18 2009 required for ry every page. Cityrrown 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. .I II ` i I A a . 204wiannocir-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 204 Wianno Circle Property Address Sephen Cockran Owner Owner's Name information is required for Osterville MA 02655 February 18, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >2 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: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Hand augered 2' below base of overflow. No sign of ground water after 2 hours. Accessed local ground water contour and topo mapping. No high ground water in area of system. 204wiannocir•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION (SAP A RECEIVED . PARCEL, , AUG 0 9 2004 TITLE 5 TOWN OF BARNSTABLE HEALTH DEPT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARYW99ESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 204 Wianno Circle Osterville, MA 02655 Owner's Name: Richard&Beth Wells Owner's Address: Date of Inspection: July 26, 2004 Name of Inspector: (Please Print)James M. Ford Company Name: James M. Ford CD� p Mailing Address: P.O. Box 49 -- Osterville.MA 02655-0049 __ d ; Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the igirmation=re6port6d below is true,accurate and complete as of the time of the inspection. The inspection was performe based oh my ti" training and experience in the proper function and maintenance of on site sewage disposal systems. I am a,6cP r- approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste rn ✓ Passes Conditionally Passes Needs Further,Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: July 28, 2004 The system inspector shall subm 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. 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 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 204 Wianno Circle Osterville, MA Owner: Richard&Beth Wells Date of Inspection: July 26, 2004, 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: 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 204 Wianno Circle Osterville, MA Owner: Richard&Beth Wells Date of Inspection: July 26, 2004 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds.indicates,that the well is free from pollution from that facility 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: 3 " Page 4 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 204 Wianno Circle Osterville, MA Owner: Richard&Beth Wells Date of Inspection: July 26, 2004 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level-in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] No (Yes/No)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 System: To be considered a large system.the system,must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system:is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 r Page 5 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 204 Wianno Circle Osterville, MA Owner: Richard&Beth Wells Date of Inspection: July 26, 2004 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 ✓ 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: Yes No ✓ _ 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(3)(b)]. 5 Page 6 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 204 Wianno Circle Osterville, MA Owner: Richard&Beth Wells Date of Inspection: July 26, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): Yes Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 15 years ago-per owner Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 Wianno Circle Osterville, MA Owner: Richard&Beth Wells Date of Inspection: July 26, 2004 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) (Cesspool acting as a septic tank) Depth below grade: 20" Material of construction: concrete _metal _fiberglass _polyethylene ✓ other(explain) Cesspool block If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: S'W x 6'T x 9'bottom to Qrade Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 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: - How were dimensions determined: Measuring stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The cesspool had 3'ofliauid on the bottom. An outlet tee was present. The cover was 20"below trade. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 Wianno Circle Osterville, AM Owner: Richard&Beth Wells Date of Inspection: July 26, 2004 TIGHT or HOLDING TANK: None (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: -allons Design Flow: Qallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan)' 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.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 ` Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 Wianno Circle Osterville MA Owner: Richard&Beth Wells Date of Inspection: July 26, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: ✓ overflow cesspool,number: / Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): The overflow cesspool was 5'W x 6'T x 9'bottom to grade and was dry and clean. No scum line was present The cover was Y below Qrade. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 Wianno Circle Osterville, MA Owner: Richard&Beth Wells Date of Inspection: July 26, 2004 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. A a a I �36 33 a 3o i� 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 204 Wianno Circle Osterville, MA Owner: Richard&Beth Wells Date of Inspection: July 26, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 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: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic maps and water contours maps the maps were showingapproximately 25'+/-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 it 9 CommONWEALTH OF MASSACHUSETTS m ,TFff . _ EXECUTIVE OFFICE OF ENNIRONME\TAL AFFA `SEP � "Ok 2 DEPARTMENT OF ENVIRON JAL PROTE N r0x�'°F 199? A yE9lTHgANc� �.y ONE WINTER STREET. BOSTON. NlA O'IOb 61 292-5:00 ' A . WILLIAV F WELD TRL•Dl COOT Govemc• Se:rc-. % ARGEO PAUL CELLUCCI DAVID B STRLHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissions PART A CERTIFICATION Property Address: okw jo h�i C? VSV-��, Address of Owner: �tj Date of Inspection: �X(Vlq� (If different) coermt— Name of Inspector: H A a o P C1 E—), EC eo I am a DEP approved system inspector pursuant to Section 13.340 of Title 5 (310 CMR 15.000) Company Name: Mailing Address: P—O e_3;5?!4 H A9&,,Ee_c H aq—© o q Telephone Number: rSp J G�. �— /(+� Zp T CERTIFICATION STATEMENT I cenif that I have personalt. .inspected the sewage disposal system at this address and tha: the information reponed beloN is true, accurate and complete as of the time of mspeo-o-. The inspection was performed based on my training and experience in the proper iunction and maintenance of on-site sewage disposa systems. The system: Passes Coo0!1,cinaiiy Passes �-eeo= Funhe! Eya!uat:on B� the Local Approving AuthoriN _ F Inspector's Signatur Date: / The System Inspector shal° submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system o• has a design floe of 10,000 god or greater, the inspector and the system owner shall submit the repo.^, to the appropriate regional onice of the Department of Environmental Protection.. The orig;na! should be sent to the systeme ownr and copies sent to the buyer, if applicable, and the'approving authorir� INSPECT10% SUMMARY: Check A, B, C, or D: ` A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303_ Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of.Health, will pass. Indicate yes, no, or not.determined (Y, N, or NDi. Describe basis of determination in all instances. If"not determined", explain why not.. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. tzev:eed W/25/97) page 1 of 10 DEP on the wono wiae weo htto.rrwww magnet state ma.ustoec Pnntnc on RectiUed Papa -,tj SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM c*, PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection-, Bj SYSTEM CONDITIONALLY PASSES (continjad Sewage backup or breakout or high static water level observed in the distribute box is due to broken or obstructed pipets) or due to a broken, settled or uneven.distribution box. The system wi pass inspection if(with approval of the Board of Health;. Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to br en or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipets are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of ealth in order to determine if the system is failing to protect the public health, safer\•and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMI S THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAF AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface ater Cesspool or prn, is within 50 feet of a border g vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEAL (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER T AT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet to a surface water supply or tributan, to a surface water supply. The systern has a septic tank and oil absorption system and the SAS is within a Zone I of a public water supnty well. The system has a septic tank an soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a se tic an a d soil P so absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, un ss a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from polluti n from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method sed to determine distance (approximation not valid). 3) OTHER (r�vifod 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO's FORM PART A CERTIFICATION, (continued) Properh Address: Owner: Date of Inspection: DJ SYSTEM FAILS: You must indicate either "Yes' or •rvo' as to each of the following: I have determined that the system violates one or more of the following ilure criteria as defined in 310 CMR 15.303. The bans for this determination is identified below. The Board of Health should contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due o an overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ound or surface waters due to an overloaded or clogged SAS or cesspool. Sta:;c !io.u;d le e! in the distribution boa above out et invert due to in overloaded or clogged SAS or cesspool liou;d depth in cesspool is less than 6" below i en or available volume is less than 112 day floe. Reouired pumping more than 4 times in the I t year NOT due to clogged or obstructed pipe's . Number of times pumped Any portion of the So;, Absorption System cesspool or privy is below the high groundwater elevation An% por-.;on o-a cesspool or priv is wi in 100 feet of a surface water supply or tributary to a surface water supply. And portion of a cesspoo' or privy is ithin a Zone l of a public well. An% pc^;o-. e-a cesspool or privy i within 50 feet of a private water supply well Any pon,or: o-a cesspool or pri. is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water qualitm analyst . If the well has been analyzed to be acceptable, attach cope of well water analysis for coliiorm bacteria. volatile orga c compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate e;.her "Yes' or "No" as to ch of the following: The ioliow:ng criteria app;v to :arg systems in addition to the criteria above: The system sem,es a iacilit\ with design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to public hea!th and safety and the environment because one or more of the following conditions exist: Yes No . the system is with 400 feet of a surface drinking water supply the system is wi in 200 feet of a tributary to a surface drinking water supply the system is I ted in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone II of a public water s pply well) The owner or operator of any ch system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5. 0 and 6.00. Please consult the local regional office of the Department for further iniormation. (revised 04/25/97) Pay 3 of 10 O SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ;Uq Owner: Ct�p Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to.each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection _ As bull; plans have been ob;a:ned and examined. Note if they are not available with N/A. _ The fac:lrty or d%%elling �.as inspected for signs of sewage back-up. _ The s\-stem does not receive non-sanitary or industrial waste flow. _ The site %%as inspected for signs of breakout. All s\stem co^)ponents. excludme the Soil :Absorption System, have been located on the site. •. _ The septic tank rnanho',es mere uncovered, opened. and the interior of the septic tank was inspected for condition of baffles or tees. material o;construction, dimensions, depth of liquid,depth of sludge, depth of scum. —The size and locatjon of the Sol' Absorption Svstem on the site has been determined based on The iaci'm owne, ;ano occupants.if dineren; from owneri were provided with information on the proper maintenance of Sub-Suriace Disposal Svstem. _ Existing information. Ex. Plan at B.O.H. _ Determined in the meld :if an% of the failure criteria related to Pan C is at issue, approximation of distance is unacceotabie (t 3.302:31.b? (revised 04/25/51) Fags 4 of 10 I _ rA SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Propertm Address: Owner: ('W-Q-%}f'1 Date of Inspection: E)w�� • RESIDENTIAL: FLOW CONDITIONS Design floe lqqPIz p.d..bedroorr for S.A. Number of becrooms Number.o'current residents Garbage g,: der (yes or nog Laundry co-•^ected to system (,yes or no' Seasonal use ryes or no-:_W Water meter readings, if available (last two '.2; year usage (gpd): 6)jr�) Sump Pump Ives or no) Las; da:e o-occupancy COMMERCIAL'INDUSTRRIIA_L`•"''_ Type of establishmex Design fiov, _ Falionvda% Grease trap present rues or no' Industna! \'taste Holding Tani; present -ves or no Non-sarr+tan y.aste d,scnargec to the T!:,e 5 sysem. ;ves or no_ \later meter readings, if a�a,labie Las:pave o) o -,;p2 :c\ OTHER: Describe Last oate of occuoanc. GENERAL INFORMATION ' PUMPING RECORDS a source of ,n ormat,on tQ 7 S\stem pumpec as par, of.inspection: dyes or no.vas If yes, volume pumped gallons Reason fo- pumping TYPE OF SYSTEM _ Septic tank/distribution box%soil absorption system Single cesspool Overflow cesspool Prn). Shared system (yes or no) (if yes, attach previous inspection records, if any) 1/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 1 � Sewage odors detected.when arriving at the site. (yes or no); : _ (revised 04/25/9*7) pay 5 of 20 SUBSURFACE SEY AGE DISPOSAL SYSTEM INSPECfIM'. FORM PART C SYSTEM INFORMATION (continued) Vtj Property Address: V%rl UCIZ Owner: Gy Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade. Material of construction. _cast iron _40 PVC _other (explain) Distance from private water supply well or suction li-t Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan Depth belov. grade Material of construeion: _concrete _meta _Fiberglass _Polyethylene _othertexpian If tank is metal, lis: age _ Is age con irmec b\ Cen;ficxe of Compitance _(Ye&,No Dimensions a�- Q A-1 Sludge depth " Disiance from top o: sludge to botto-n of ou6e: tee o• ba,")e V-6I a. Scum thickness:; Distance from top of scum to top o�outlet tee or ba4ie k " 11 Distance from bosom of scurn to bo-o•n of ouiie; tie or bane How dimensions were determined Ll Comments. (recommendation for pumping condition o� inlet and outlet tees or baffles depth of,liquW Revel in relation Aoutlet invert, structural i tegnty, evidence of leakage, e;c.t, i GREASE TRAP: (locate on site plan; Depth below grade: Material of construction. _concrete _metal Fiberglass _Polyethylene _other(expbihi) Dimensions: Scum thickness: _ . ..... _ Distance from top of scum to top of outlet tee or baffle. Distance from bosom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquidlievel in relation to outlet invert, structural integrity, evidence of leakage, etc.: (revised 04/25.17) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propert. Address: wt1wtNO-C> 0%ner: Date of Inspection: 1 � TIGHT OR HOLDING TANK: lank must be pumped prior to, or at time, of inspection: (locate on site plan, Depth below grade Material of construction. _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacm galions Design floes gal;ons•oa. Alarm level A;arm rr wonting order_ Yes. _ No Date of previous pumping Comments (condition of inlet tee. condauor o• warm and float switches, etc.) DISTRIBUTION BOX: (locate on site par Depth w liquid le e! aoo.e outle: rn%e,7 -� ' �, 0Q'4Zs.T� ' Comments mote if leve! and dwnb-j�!or is e ua! vidence of solids carryover, evidence of I kage into or out of box, etc.) PUMP CHAMBER: (locate on site plan_ Pumps in working order: (Yes or No, Alarms in working order (Yes or No, Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/9,) page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ' PropertT Address: W1/tt`iN0 Owner: r^j �j Date of Inspection: ef'z(,'q 7 SOIL ABSORPTION SYSTEM (SAS): (locate on site.plan, if possible, excaTon not required, but may be approximated by non-intrusive methodso If not determined to be present, explain: Type: I leaching pits, number. a,$ leaching chambers, number:_ leaching galleries, number: leaching trenches. number,length: leaching fieids, number, di^nension.s over.•!ow• cesspool, number Alternative system Name of Technoiog\ Comments. mote condition of soli. s!grs of hydraulic failure, level of pondrn conditi of getation, etc.) 1 CESSPOOLS: I� (locate on site plan Number and configura:.or. Depth-top of liquid to inlet rnver, Depth of solids layer Depth,of scum layer. Dimensions of cesspoo Materials of construction Indication of groundwate- inflow tcesspool must oe pumpeC as par, of rnspeclion:.1 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.) t:.Y.%..d 04i2si97l page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continuedi Propert% Address: V)I woo Owner. CA)W-VAN. Date of Inspection: ! \a(P1 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reierences landmarks or benchmarks locate all wells within 100 (Locate where public water supply comes into house) t b U 1S ILL-as �� (zaviaa: 04'25 5-,) Page 9 of 10 i _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ' Property Address: { /�(` � Owner: Date of Inspection: 'ta 152 Depth to GroundwatertWFeet Please indicate all the methods used to determine High Groundwater Elevation: Obtained irom Design Plans on record Observation of Site (Abutting property. observation hole, basement sump etc.) Determine it from local conditions Cnec'K with local Board o• nealtr, Check FE.mA maps Check pumping records Check local excavato,s. installers Use LSCS Da'a r. Desciibe in vox o�.: %-.oro; no-,+ you es:abh hed the High Groundwater Elevation. (Must be completed: (�•S. wIad�o 1Nt/C�Ti '�S1 i -ITl� S �"� fe�7 lzav:aad 04;25'9-. Page 10 of 10 co LOT .� .3 137co co 77 B�31 yam`-' S C11 \' Z East 8 . a ¢ 4 F � 5 _ a p• •� n a a -Beacn Neck z L - S 89*08'00" E 133.61' `161 1 ► W A6 4 SHED -0- LOT 133 o LOT 138 0 LOCUS MAP 1 � 13,500 S.F. �\ o �---� OF F' _ J ao _ _ 1-4 EX1St1 r — � , — � G I � RS JONN , . ; I -G LEY rn Brick i U �E Patio I I - .35101 i o NOTES: T R° w 1 \ TP 1 i TP 2 I� LOT 138 IS SHOWN IN THE ZONE o� J I o sePugl ► - Q LOT 138 1S SHOWN IN THE "RC" ZONING. '—' DISTRICT 0 32.9'1 5.5 x16.0 x. 0 1 D ADDITION ti I'' 3 55.1' i 1,871 ESX•IF T(13.9%) CO O VERAGE IS p t / O � q N / i P 5p : T COVERAGE f p . 1,959S.F. (14 %) a z• t garage I WIND. EXPOSURE ZONE „B»exising ♦/ 32.8' I gravel - dr ive it \. 10.61 `ii LI HOUSE # 204: septic .1 P ` .;, ,• g I II_ �� �3 IR EXISTS . ROPER o ` pj 0 . RIGATION ON THE, P TY r�, 95.3' CDSITE PLAN � o O to I �� of PREPARED FOR RICHARD & SHARON BRIANSKY LOT 132 VENT ." OF a PIPE H 204 WIANNO CIRCLE OSTERVI LLE, MA. J. E. LANDERS—CAU LEY, P.E. LOT 139 CIVIL ENVIRONMENTAL ENGINEERING P.O. MA 02574 BOX 364 WEST FALMOUTH - __ Sfax 540 334 — —_ _ - H = _ _T SCALE: - 2 DRAWN BY: S --= 1 0 � _ P/JR SCALE: 1 = 20' C RET. 16 13 JDR JOB NO. 2240 SHEET: 1 OF 2 F.F. ELEV.=103_84 BRING END -COVERS TO.'WITHIN 6" OF FINISHED ,GRADE' TO -BE USED 20'MIN. ELEV.= 1Q2_2 AS OBSERVATION "PORTS. r 101.2 CONCRETE COVERS -102.1 _ 4" CAST IRON OR ELEV. ---- SCHEDULE 40 P.V.C. 4" CAST IRON OR SCHEDULE 40 P.V.C. DIST.=35.4' Y4" -CAST IRON, OR _ SLP 0._005 12"MIN. 1., LAYER SLP.=O.02- SCHEDULE 40 P.V.C. ' - �8 -1/ OF r CONCRETE,'COVER DIST.=ll_72 WASHED STONE INVERT DIST.=95.3' - FLOW LINE ELEV.= 100_26 99.55 ----- SLP.=O.A2 INVERT °�'°v°v°v°�'°�'°v°�'°v°�'° °a °v°�'0�'°"o"o"°�'°�'0�'o�'°�'°�'�" ---- o ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° ° o ° ° ° ° � ELEV.= 99.5 19" ELEV: 97.17 ,o°°°o°°°°°°°°°°°°o°°°° °°b°°�°°g°°o°o$°o b°°v°°� 10" MIN. . ELEV. 99_30' _ v v `� E@00 ®®®® o 0 0 0 0 0 0 0` z4" LAYER OF *INVERT SHALL,BE FIELD TIM LENG BArm TH of ELEV.= 97.39 ELEV.=97.22 0 0 0 0 0 0 ®®®�®®®�®®® o 0 0 0 0 0 0 /4" To-1-1/z DEOTERRMINE UTLET BY THE a O�ODO�0 0�0-0„ oc 0�060�006000C`W ®®®®®®®®®®® ASHED STONE VERIFIED PRIOR TO THE QUID DEBTS of LENGTH of ]� BOX o„o 0 0 o - o ®®®®®®®®®®®, o„o,,o 0 0 0,,r) 95.17 px, INSTALLATION OF ANY THE TANK USED. _LIQUID OUTLET TEE ELEV.=95 (SEE CHART AT RIGHT) DEPTH, BELOW FLOW LINE SEPTIC SYSTEM 4 FEET.......14 INCHES - ° JUSE' STONE`TO a COMPONENTS. 5 FEET.... 19 INCHES SE H-20 LOADING LEVEL THE BED" � z - -, 1500 GALLON SEPTIC TANK s FEET-......24 INCHES TO BE WET TESTED IF 3. ® 4 10 x 8:5 LEACHING CHAMBERS TO BE PLACED ON SEE 310 CMR t MORE THAav ONE OUTLET. .: AS NEEDED. WITH 3' OF 'STONE ON. THE SIDES AND » 15.227 (6) ' 6 OF STONE OR ACED ON,; BETWEEN AND 3'. OF STONE ON THE ENDS 6" OF STONE OR L. A'x MECHANICALLY COMPACTED "SOIL. . .USE, A. TANK WITH THREE CO , BOTTOM OF HOLE OR USGS PROBABLE WATER TABLE ELEV ' SOIL TEST DONE BY J.K: LANDERS-CAULEY P.E. - - ��� 0� USE H-20 LOADING p WI IF -MORE THAN 4 OF COVER. WITNESSED BY. _DON'D `------------------ o� t S PERCOLATION RATE: 5___MIN/INCH P# 14056 /� oyCAWLEY 07 08 13 _ 102.2 �' U �. •� -,: ,` ,_ TEST .HOLE=.1 DATE. - -- -- ELEV.------- - 1 o.35 Ot z� x -r PROFILE OF DEPTH HORIZON TEXTURE ' COLOR MOTT. OTHER,, p SEWAGE DISPOSAL SYSTEM - ssioNA< = 0 -11 FILL NOT TO - f _ ` BY THE 11 22 0` A DEPARTMENT I CERTIFY TOF ENVIRONMENTAL CURRENTLY PROTECTION PURSUANT TO 310 r". � IL EVALUATIONS AND THAT CT EMR IANALYS S GIVEN HAS 5.017 TO CONDUCT OBEEN PERFORMED GENERAL NOTES: 22„-42" ' 5/6 B SANDY LOAM lOYR BY ME CONSISTENT WITH THE REQUIRED TRAINING,x _ THAT THE DR RESULTS OF R ' EXPERTISE, AND EXPERIENCE ED 82 84 15.017. I FURTHER CERTIFY --1. THIS •PLAN IS FOR THE REPAIR OF AN EXISTING' ° SEWAGE DISPOSAL SYSTEM: 42"-84" Cl±_ MED ;SAND• IOYR:=-5 8 - RED .HUES MY SOIL EVALUATION, _AS INDICATED ON THE ATTACH / -SOIL EVALUATION FORM,°ARE ACCURATE AND IN 2. PLAN REFERENCE LC 2664=83. - LOT 138 ; BARNSTABLE REG. OF DEEDS. ACCORDANCE WITH' 3,10 CMR 15.000 THROUGH 15.017. 3. THIS PLAN IS`-FOR THE INSTALLATION' /REPAIR OF SEPTIC 'SYSTEM AND- NOT TO BE USED FOR SURVEYING .AND ZONING PURPOSES. .-- » DESIGN DATA: 4. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. 84 -126 C2 FINE SAND` 10YR _6/4' NO H2O TITLE 5 AND THE TOWN OF BARNSTABLE' RULES AND REGULATIONS '. ENC'D FOR THE SUBSURFACE DISPOSAL OF SEWAGE: W ' NUMBER MS -FQH8.-(4)----R OF BEDROOMS 5. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO, WITHIN TEST HOLE ,2 DATE. 0708�13 ELEV._101_9 :__ a GARBAGE'DISPOSAL _WliE-W =---- 6" OF THE FINISHED GRADE. • ` a - �°�• DEPTH, ' HORIZON TEXTURE`- COLOR,- r MOTT. - OTHER` 6. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY THE TOTAL ESTIMATED,FLOW '_44Q_____ GPD SAME, UNLESS NOTED BY FINAL CONTOURS. 0"-11" FILL ` 7. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE ( 1 __.GAL/BR./DAY. X y___ BR. ) OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR 11-"=22" " 0 f A = ' ' SEPTIC TANK CAPACITY �QQSxAL,__ WITHIN 10' OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE USED UNDER OR WITHIN 10' OF DRIVES OR PARKING LEACHING RE AREAS UNLESS NOTED. 22"-42" T' SANDY LOAM 10YR 5/6 HI G AREA REQUIREMENTS 8. ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL x SIDEWALL AREA 393.32 S.F. BE MORTARED IN PLACE. 82"-84" 9. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH 42"-84 C1 MED. SAND , , 10YR 5/8 RED HUES BOTTOM AREA _4Q S.F. DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO r - - OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY. LEACHING CAP.(BOT. & SIDEWALL)_ 443.59GAL 10. THE EXCAVATOR/CONTRACTOR SHALL VERIFY THE LOCATION OF m'?-126" C2 FINE SAND 10YR-6/4' .' NO -H20 ALL--UNDERGROUND-UTILITIES_PRIOR-TO ANY EXCAVATION._ __ _ LL _T _ .,- __ _ _ __ __ . ._ . RESERVE LEACHING_-CAPACITY-_V-A____GAL. ENC D - - - _-- � � &--S ---BRIANSKY= DAT-� � 07 ��09 13 -..- - -- -.�..:CHARD HARON E. _ -� _ ----- - AP-PLIGANT RI � / NOTE: :-THE__T0-WN -0F -BARNSTABLE-- REQUIRES THE ENGINEER TO INSP_EGT ALL :SEPTIC_ SYSTE-M--COMPONENTS, �_;-. - - - �--� =-- - - - -- - -- - - - INCLUDING INVERTS, AFTER THEY HAVE BEEN INSTALLED- AND BEFORE THEY ARE BAGKFILLED. -REVISED:.08/06/13 JDR 09/16/13 SHEET 2 OF 2 JOB # 2240 a , i = 1 P-6" 16'-0' P.T.8 x 8 POSTS W/ AZEK OR KOMA CASING &10•HIGH BASE L_d-in 1 --------------- EXIST. A A KITCHEN L As ! I 2$ s 4 EXIST. I, ! 4x 10 BEAM ABOVE I ,Q�5 SUNROOM I ___= NEW ED ==- �� 4 COVER W IODPQP,v„� I � D a I PORCH BPS m 4 •`zX 4 ---i _ I (VAULTED CEILING) O I I 1 B -_.-_-4x10 BEAM A80E -- -- I _____ ________- � �iI � STEP DOWN ANDERSENI ANDERSEN qw - - TW21046 TW21 ' EXIST,..-' --DINING w q EXIST. - MUDROOM F EXIST. - GARAGE ON. EXIST. • j CLOSE• BATH q 1 I i N { I EXIST. LIVING CLOS# I EXIST. BEDROOM. I EXIST_ UP HALL ` FIRST FLOOR PLAN Lo . - ���j LEGEND: NEW D I DOOR 0 EXISTING WALLS I - r--� NEWANDERSEN - NEW N - CONSTRUCTION TO BE REMOVED1 A DERS N 3'•8" TW2448-2 MULL 3'-6' . TYJ2446-2 M LED NEW CONSTRUCTION N1N°O" i qg s `WMDO� 4 4 B m NEW COVERED NEW P.T.6 x 6 POSTS W/AZEK OR ,YdCASING&8"HIGH BASE AB ® PORCH AA ACH TO FOUNDATION W/ SIMPSON ABU66 POST BASE r 28'1• ? 38'-W THE DESIGNER SHALT.BE NOTIFIED IF ANY COTUIT BAY DESIGN, LLC NEW ADDITION/REMODELING FOR: ERRORS OR AWINSPRICRREFWNOGN SCALE DRAWINGNO..: . THESE DRAWINGS PRIOR TO STAR-OF CONSTRUCTION.THE BUILDING f.ONTTLICTOR _ 1 11 WILL BE RESPONSIBLE FOR THE CONTENT 1/411 - 1 -0 43 BREWSTER ROAD IN THESE DRAWINGS IF CONSTRUC ON MASHPEE ,MA. 02649 B R I A N S KY RESIDENCE ' COMMENCES WITHOUT NOT EYING HE PH. (508 274-1166 DESIGNER OF ANY E SOLELY OMISSIONS. TNESEOFIA ERNOTRE SOLELYFOR THE USE _DATE FAX(50�)539-9402 �((��\/A1 THESEDWWINGSTED.ANYDTHERUSEOF 10/30/2015 204 WIANNO CIRCLE OSTEFVILLE, IVIA THESEORAW NGS REpUIRES THEWR TEN Al CONSENT OF THE DESIGNER UNDER THE ARCHITECTURAL COPYRIGHT PROTECTION ACT OF 1990. 27'� L. z L, SUNROOMlKITCHEN ) A A ` t? ROOF BELOW - A6 6 PORCH ROOF BELOW m {; 38'Ar ° AG NEW ANRSEN 7 A251 INell WS\ CLO EXIST. nw T. CLOS. OBATH BATHo N EXIST. � - BEDROOM EXIST. HALL DN.. i 4 CLO8. EXPANDED -� EXPANDED BEDROOM I BEDROOM I II I l��'v/ X6 II I I� 1 -, --- -------------- ---- -------- AND. AND. AND. AND. AND. 2 A251 TW2442 AND. AND. - TW2442 TW2442 AD.TW2 AND, 2 2'-0' 2'-10 '-71/2' S'-7 1 2% 2'-0' 2'-10° 2'-0" 4 BC B 6 6 3'-81/2° 3'-81/2' " (GABLE DORMER) C (SHED DORMER) - (GABLE DORMER) A6 LEGEND. 25'-0° 38'-0° 0 EXISTING WALLS \ L--J CONSTRUCTION TO BE REMOVED SECOND FLOOR P LAN ISM NEW CONSTRUCTION ME DES GNER 9�1_BE NOTIFIED IF [� NEW ADDITION/REMODELING FOR: THESEDRRINSPRIORATOSTATONE SCALE : COTUIT BAY DESIGN. LLC ERRORS OROMISIONSAEFOUNOF DRAWING NO.: CONSTRUCTION.THE BUILDING CONTRACTOR 1/4" "' 43 NEW ROAD WILL BE RESPONSIBLE FOR TMECONTENT - R C IN THESE DRAWINGS IF CONSTRUCTION MAS H PE E MA. 02649 B R I A N`/KY RESIDENCE COMMENCES WITHOUT NOTIFYING THE V OE ME OWNER OF ANY ERRORS OR OMISSIONS. PH. (508)274-1166 _ _ THESE DRAWINGS ARE SOLELY F..THEUBE DATE FAX(508)539-9402 TH THEDRAWING REQU=REB INERUSEOF 204 WIANNO CIRCLE OSTERVILLE, MA THESENTOFMSREIGNER NERMEN 10/30/2015 CONSENT OF THE DESIGNER UNpER THE ACT OF CRIRAL COPYRIGHT PROTECTION ACT OF 1BB0. I ' 'i I J 23'-0" 5'-8 1 16'-0" 12"DIA.CONCRETE SONOTUBES ON 28'DIA.BIGFOOT FOOTINGS TO 4.0•' I BELOW GRADE.USE SIMPSON ABU66 I POST BASE I INSTALL FLASHING UNDER HOUSEWRAP&DECKING I DECKING I > --- \ 3-P.T.2 x 12 BEAM FLOOR JOISTS A A P.T.2 x 10'B @ 1r o.c. Gf - A6 2•-6' 6 4 cj IO — INSTALL PEEL&STICK c RUBBER MEMBRANE Q BETWEEN LEDGER& J I B SHEATHING Ag I I P.T.2 x 10 LEDGER BOARD LAG BOLTED TO 4'-0' 2 z 6 FLOOR.JOISTS SOLID BLOCKING W/(2)LEDGERLOK BOLTS 16'o.c.STAGGERED W/JOISTS HANGERS @ 16"O.c. � I EXISTING I I CRAWLSPACE -I -2. - DECK DETAIL NE D'e C&lr O.C. SAWCUT FOUND.WALL W/MID-SPAN BLOCKING 4 FOR ACCESS INTO NEW C RAWLSPACE LLLL • —FOUNDATION &FOOTING FOR P.T.2 x 10 LEDGER BOARD LAG BOLTED TO FIREPLACE, SOLID BLOCKING (2)LEDGERLOK BOLTS MASON TO VERIFY 16'o.c.W/JOISTS HANGERS IN THE FIELD I 4 EXIST. _ CRAWLSPACE EXIST. GARAGE EXIST.GIRT , _—_—___�———_—____e___—_—_—__ _2 x 6 FLOOR JOISTS l F— O m EXIST. L BASEMENT UP I NEW 8-CONCRETE FOUND. 4"CONC. LAB I I WALLS W/8'z 1B"CONCRETE _ I ON COMI OR ACTEDMASON YI I I q FOOTINGS T04'D"BELOW GRADE FOUNDATION PLAN A6 ; I L LATFO ABOVE I i s 22'-W 38'-0' III CCTUIT BAY DESIGN. ��c NEW ADDITION/REIVIODEL'INC� 'FOR• THEDEDRAWINSNLBENOSTARIFANY SCALE . DRAWING NO.: L� I ERRORS OR OMISSIONS ARE FOUND ON Ea THESEDRAWINGSPRIOR D STARTTR CONSTRUCTION.THE BUILDING COMPACTOR 11� It 43 BREWSTER ROAD WILL BERESPONSIB�EFOR THE CONTENT - 1/4 11 -O IN THESE ORAWINGS IF CONSTRUCUON BRIANSKY RESIDENCE COMMENCES ANY NOT OR OMISSIONS THE MASHPEE MA. 02649 THESEDR OF WINGSARRORSGROMISBIONS. DATE : �� THESE DRAWINGSSAKE SOLELYFOR THE USE PH. (508)274-1166 OF THE OWNER NOTED.ANY OTHER USE OF FAX(508)539-9402 204 WIANNO CIRCLE OSTEFZVIL:LE, MA HESEDRAWINGSREOUIRESTHEWCTION 10/30/2015 CONSENT OF THE DESIGNER UNDER THE PACHITECTU THE COPYRIGHT PROTECTION ACT OF 1 M 103.84 • F.F. ELEV. ; BRING. END COVERS TO: WITHIN 6 20'MIN. OF FINISHED .GRADE TO BE USED ELEV.=102_2 - AS OBSERVATION PORTS 4 CAST IRON OR ---- CONCRETE COVERS SCHEDULE 40 P.V.C. 9„ MI�NT ELEV. 101.2 1021: .COVER 4' C DU IRON OR 12"M�IN. 4" CAST.IRON OR SCHEDULE 40 P.V.C. y 2'IVIA DIST.=28.2_. . SLP.=0.02_ SCHEDULE 40 P.V.C. SLP:=0._005, BI�nY/E2 of . X INVERT DIST:=107.4' coxcRETE COVER DIST. IT,I v°vov *100:26 FLAW LINE ----- SLP:=0.007 o�o„a °„a„° o„o„oF, VTOP ATI CHAMBER o.,o.o.,°.,o.,o.;°;.aaoHoD STONE, ELEV. 0 2 99 "70 SINVERT o°0°000°000°0°0°0°0°0° o°0°0°000°000°0°0�0°0°0°0�ELEV.= -_ ELEV.= 98.42 10" MIN. 19" O-O-O-O.-O-O-P-O-O-O-O -O63 ° -OO°- -Ob°-OjO:< 24 LAYER 0 s THE LENGTH of ELEV.=_99:45 98.64 0"0"o"o'-' ®®®�®®®®®® °oho°o°o°o°o°o° /4 INVERT SHALL BE. FIELD ouTLET TEE Is H ELEV.- 98 ELEV.=98 47 1-1Nz VERIFIED PRIOR TO THE Denum IED BY THE - - 0.0C 000oop0000 0000. 00000oo00c'W " TO LIQUID DEPTH DF "'LENGTH'OF -DISTRIBUTION .BOX:. - n O O O O .O .O ®®®®®®®®®®® O-O,;.0 O O; O„O� WASHED �ST60� INSTALLATION OF ANY THE TANK USED. LIQUID . OUTLET TEE DISTRIBU ELEV..(SEE CHART AT RIGHT) DEPTH BELOW,FLAW LINE USE H-20 LOADING. SEPTIC SYSTEM s SET.......is irNrcHEs USE STONE TO COMPONENTS. 1500 GALLON SEPTIC TANK a FEET.:.. ..z4 INcxEs TO BE WEV TESTED IF: LEVEL -THE BED, 3 ® 4 10" x 8.5 :H-20 LEACHING CHAMBERSS 0, TO BE PLACED ON . AN 0 TON SEE s10 cMR MORE TH ONE OUTLET.: AS NEEDED WITH 3 OF S E ON THE SIDES AND 15,zzz (s) BETWEEN :AND 3 OF .STONE' ON THE ENDS 6 OF STONE OR TO BE PLACED ON MECHANICALLY COMPACTED -SOIL. 6» OF STONE OR l USE A TANK WITH .THREE COVERS. MECHANICAL LY COMPACTED SOIL: ----- BOTTOM OF TEST HOLEOR,USGS PROBABLE WATER. TABLE :EI°EV 1 4 USE H-20 LOADING SOIL TEST DONE- BY: J.E.. LANDERS-CAULEY P.E. IF MORE THAN 4 OF COVER. WITNESSED BY. _DON' D--=-------=-----=-- 4 PERCOLATION RATE: =5___MIN/INCH P# 1 056. TEST HOLE 1 DATE: 0�08113_ ELEV._L02_2 __ PROFILE O F - DEPTH - HORIZON TEXTURE. COLOR MOTT. OTHER.` •, - .- SEWAGE DISPOSAL SYSTEM = 0„ 11- FILL. SECTION A-A NOT TO SCALE . 0/A DEPARTMENT OF ENVIRONMENTAL Bf THE LPROTECTION D.PUR UANT 0 310 CMR 15.017 TO CONDUCT SOIL EVALUATIONS .. T AND • ER 22»-42» B', SANDY LOAM lOYR ,5 6 BY METCONSISTEN THE T WITH SIS ITHE REQUIRED TRAINING, VEN HAS BEEN ED GENERAL NOTES: _ � / 42» � EXPERTISE. .AND.EXPERIENCE DESCRIBED IN 310 CMR 82,,. 84,. — 15:017. I FURTHER CERTIFY THAT THE RESULTS OF „ ,� MY SOIL EVALUATION, AS INDICATED ON THE ATTACHED 1. THIS PLAN IS FOR THE REPAIR OF -AN EXISTING SEWAGE DISPOSAL SYSTEM: 42 -84 C1, MED SAND 10YR 5/8 RED HUES SOIL EVALUATION FORM, ARE ACCURATE. AND IN 2 PLAN REFERENCE LC 2664-83 ' LOT 138 BARNSTABLE REG. OF DEEDS: `' ACCORDANCE WITH 310 CMR 15.000 THROUGH 15.017. 3. THIS PLAN IS FOR THE INSTALLATION /REPAIR OF SEPTIC SYSTEM. AND NOT TO BE USED FOR SURVEYING AND ZONING PURPOSES. PERC: DESIGN DATA: 04 -126. C2,', FINE :SAND 10YR 6/4 NO H2O 4._ ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TEST NC'D TITLE 5 AND THE TOWN OF BARNSTABLE RULES-.AND REGULATIONS E FOR THE SUBSURFACE DISPOSAL OF SEWAGE. MS _FQUR_(4� . NUMBER OF BEDROOMS 5. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO WITHIN TEST HOLE 2 RDATE. 07�08�13_. ELEV._101_9___. -� �, _. E COLO GARBAGE DISPOSAL NONI•v_W�-- x� 6" OF THE -FI•NISHED GRADE: v-, .,YHORIZON .. r DEP' H T XTURE R �� Q ER = 6. EXISTING AND FINAL GRADES SHALL REMAIN ESSENTIALLY. THE SAME,. UNLESS NOTED BY FINAL CONTOURS. 0 -11 FILL HN T ESTIMATED. FLOW _ s- �Ev ES GAL./BR./DAY X. �4 BR ) r � TOTAL 7. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE o �.� OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR U - 11Q 11"-22" 0/A ' 351 SEPTIC TANK CAPACITY ISQQ AL_ WITHIN 10' OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE USED UNDER OR WITHIN 10' OF DRIVES OR PARKING.. ' . . „ - AREAS UNLESS NOTED. 22 .--42 . B SANDY LOAM lO.YR 5/6 LEACHING AREA REQUIREMENTS. 8. ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALLp � SIDEWALL AREA 393.3 S.F.' BE MORTARED IN PLACE. 82 —84 9. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH 42"-84 C1 MED SAND lOYR. 5/8 RED. HUES BOTTOM -42F13— S.F: AREA DEEDED OR ZONING REGULATIONS. OWNER/APPLICANT IS TO OBTAIN SUCH DETERMINATION. FROM APPROPRIATE AUTHORITY. C AP.(BOT. & SIDEWALL)_j_ — GAL LEACHING C 10. THE EXCAVATOR/CONTRACTOR SHALL VERIFY THE LOCATION OF. PERC. 84 -126 C2 FINE SAND,- 10YR 6/4 NO ' H2O ALL UNDERGROUND UTILITIES PRIOR TO ANY EXCAVATION. TEST C'D RESERVE LEACHING ..CAPACITY _JA --_ GAL. EN APPLICANT: RICHARD & SHAR /ON BRIAN. DATE:,07 09/13 NOTE: THE TOWN OF BARNSTABLE ,REQUIRES THE ENGINEER TO. INSPECT ALL SEPTIC SYSTEMS COMPONENTS, ' INCLUDING INVERTS, AFTER THEY,HAVE. ,BEEN INSTALLED AND BEFORE THEY ARE BACKFILLIJ'D. REVISED: 08/06/13 IJR 00/26/_13 SHEET 2 OF 2 JOB # 2240 s �A r t CO00 'a LOT 137 .$ ';• `o� , .cn� �,:. ry Z a - [y - � owse�> Beelch O — ' — _ _ ram• i ••�� L :�. - U —. -- Neck Z L _ 89,0 �O 1p1 a. ?. gvw:. ryatal' l S 8 0 E.\ . .133.61 Y 1 _ �- La a ij 1 -o- SHED ra Qn LOT 133 ► , �� LOCUS MAP o LOT, 1 8 , Cl1 — 13,500 S:F: G\ I - - - _ - -_ Exist1W, B rick J G ' NOTES: Patio I �� ,� d- I i� . o �W LOT 138 IS SHOWN IN THE C.. FLOOD ZONE cat i ic o LOT 138 IS SHOWN IN THE "RC" ZONING .� TP 1 wI o � DISTRICT. . 2 i O 9epu5 Q : THE EXISTING LOT COVERAGE IS co i 7 9.. 1,871 5.5 x16.0 p x 183' 0 32.9' ADDITION do 1 T SE LOT COVERAGE IS z O 1,959PS.FP (145%). . x I 55.1' i W o WIND EXPOSURE ZONE "B„ �� �o CD , O .a 9, 4.1. C�AN W z existing N --��_ �� � � HOUSE. # 204. I" .32.8'i a� garage s' d i _ ravel .drive CA 1 lf� . i ► 5-9- 10.61 11 IF THE IRRIGATION SERVE AREA THE CONSTRUCTED, a i IS , t _ septic x, f .�. �iI THE WATER LINE SHALL BE-EITHER DOUBLE ... 1 y o r ; i Ott. F NCASED�. R RELOCATED. 7 . 0 CO\ CQ - 50' r-, CDZp ULEY c n to CLEAN .-�OUT 107.4 4 � 5101 SITE PLAN ' o � c°� .o PREPARED FOR z N 88°56'30" W 130.00 HAR Y RiCHARD & S ON BRIANSK VENT "'c.. :j {m OF. �+ LOT 132f PIPE H 204 WIANNO CIRCLE. . . 3 ® 4' _0" x 8' 6 OSTERVILLE, MA. H=20 LEACHING CHAMBERS ERSCA_ EY, P. E. LOT 139 CIVIL ENVIRONMENTAL ENGINEERING P.O. BOX 364 WEST FALMOUh., MA 5 - — .. 1'H =� P 508 540 7733 74 0' 20' 30' 40' 508 540 3344 fax V.0 40 8 s , 9 26 1 3 JDR ASS. 1 DATE: 07109113 ,, . RE.-09 25 13 JDR SCALE: 1" I oti0, DRAWN BY' SP/JR - r AL RE4�,:: SCALE:1+J. 20 REV.09�16 13 JDR JOB NO. 2240 SHEET: 1 OF 2