HomeMy WebLinkAbout0234 WIANNO CIRCLE - Health 234 Wianno Circle
Osterville
A= 140-105
v
Commonwealth of Massachusetts A/0--6QS
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
234 Wianno Circle r .a
Property Address
P�3
Reilly ;
Owner information Owner's Name r
is required for every page. Osterville ✓ MA 02655 1/29/18 X.
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.
A. General Information
1. Inspector:
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth r MA 02536
Cityrrown State Zip Code
508.272.6433 13010
Telephone Number, License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
1/29/18
Inspecto ign Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of`...
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:_Subsurface Sewage Disposal System•Page 1 of 17
olyd 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 234 Wianno Circle
Property Address
Reilly
Owner information Owner's Name
everyage. r Osterville MA 02655 1/29/18
every page.
Citylrown 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:
13) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need'to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the.
Board of Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 234 Wianno Circle
Property Address
Reilly
Owner information Owner's Name
everyage.ed r Osterville MA 02655 1/29/18
every page.
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): .
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): .
❑ distribution box is leveled or,replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a'salt marsh
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
234 Wianno Circle
Property Address
Reilly
Owner information Owner's Name
is required for Osterville MA 02655 1/29/18
every page.
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the'SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes' No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
GM s 234 Wianno Circle
Property Address
Reilly
Owner information Owner's Name
everyage.ed r Osterville MA 02655 1/29/18
every page.
Cityrrown 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.-
E] ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public,well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the_Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 234 Wianno Circle
Property Address
Reilly
Owner information Owner's Name
is required for every page. Osterville MA 02655 1/29/18
Cityrrown 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?
El ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® El ' Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information .
Residential Flow Conditions:
Number of bedrooms (design): 5 Number of bedrooms (actual): 5
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 234 Wianno Circle
Property Address
Reilly
Owner information Owner's Name
is required for every page. Osterville MA 02655 1/29/18
City/Town State Zip Code Date of Inspection
D. System Information ,
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last'2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 1/15/18Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap'present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ :Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 234 Wianno Circle
Property Address
Reilly
Owner information Owner's Name
is required for Osterville MA 02655 1/29/18
every page.
Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: No recent pumping per owner
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
El Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy-of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 234 Wianno Circle
Property Address
Reilly
Owner information Owner's Name
is required for every page. Osteryille MA 02655 1/29/18
,
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
2010 per BOH record
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10'feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
18,,
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank, no adverse conditions
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑, No
Dimensions: 1500g '
4
Sludge depth:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
234 Wianno Circle
Property Address
Reilly
Owner information Owner's Name
is required for every page. Osterville MA 02655 1/29/18
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
>12"
Scum thickness trace-1/2"
„
Distance from top of scum to top of outlet tee or baffle >2
>211
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping suggested evry 3 years to prolong the life of the system
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 234 Wianno Circle
Property Address
Reilly
Owner information Owner's Name
is required for every page. Osterville MA 02655 1/29/18
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level_' Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date o
Comments (condition of alarm and float switches, etc.):
o �5
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
R
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
234 Wianno Circle
Property Address
Reilly
Owner information Owner's Name
is required for every page. Osterville MA 02655 `1/29/18
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 011
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.):
D-box is 2'6" below grade, cover raised to 12", very good condition
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ' ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why.
K t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts -
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�<0 234 Wianno Circle
Property Address
Reilly
Owner information Owner's Name
is required for every page. Osteryille MA 02655 1/29/18
Cityrrown State Zip Code Date of Inspection
D. System Information (cost.)
Type_
❑ leaching pits number:
® leaching chambers number: 7 Infiltrators
❑ 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.):
H-20 infiltrators were video inspected and are damp at this time, no evidence of past backup, they are
end loaded, bottom approximately 4' below grade
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.doc•rev.6/16 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
G M „ 234 Wianno Circle
Property Address
Reilly
Owner information Owner's Name
everyage.ed r Osterville MA 02655 1/29/18
every page.
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Soils are compact and dry
e
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.):
r
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
TOWN O BARNSTABLE
LOCATION e SEWAGE# n��� Ole
VILLAGE &6fv.'#e ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO. SD00
SEPTIC TANK CAPACITY _
LEACHING FACILITY:(type) ✓' (size) �•Nf�CJ
NO.OFBEDRO MS
OWNER
PERMITDATE: COMPLIANCE DATE: d
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 lemming facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
i
i l
&a
S /or,
b� 71/ll
Q
y ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
234 Wianno Circle
Property Address
Reilly
Owner information Owner's Name
is required for every page. Osterville MA 02655 1/29/18
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
Check cellar
❑ Shallow wells '
Estimated depth to high ground water:
° 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: 2010 NGW 132"
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:'
Site on 30'contour
You must describe how you established the high.ground water elevation:
See above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
't5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-'Page 16 of 17
' e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
234 Wianno Circle
Property Address
Reilly
Owner information Owner's Name
is required for every page. Osterville MA , 02655 1/29/18
City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
E System Information—Estimated depth to high groundwater ,
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
1
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,KE �Depark�nGlat og regulatory Selrvices .
Public HealfljiDivision } �� ,Date
200 Main Street,Hyannis MA 02601
'050- 1�
Date Scheduled V Tithe Fee Pd. 0
Soil Suitability Assessmentfor.Sewage
jdsposal
i'crfonned Dy: ,F ' I o"� Witnessed By.: Jt- w•' " :S.
LOCATION 4.�'l3ElYJVA®.L-S1L 111VA,OJL81V1lATIOl"! rJ �1
Location AddressOwner's Name
�I✓�1pV�U 4C f c� )-,._1
W 1 �i✓ ✓� t�' \_ ` { � Address
{ C
Assessor's Map/Parcel: '�'f oll0 L "`` Engineer's Name J(l q�tk �/ 'e
NEW CONSTRUCTION REPAIR Telephone It
d
y
land Use' 1 Slopes(%) r Surface Stones
Distances froth: Open Water Body ft Possible Wet-Area ft_ Dfiuking Water Well ft
Drainage Way " ft Property,LlneI[ Otherft
S�'TCHL (Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands li proxiuuly to lioles)
36t e
�H\ i
0 � - -�, T De Ut to Bv'(Iruck
Parent material tKeolo ie
Depth to Groundwater: Standing Water in Hole: Weeping 1'1011)Pit Pftce
� P
Estimated Seasonal High Groundwater
D]CTEMUNATION FOR SEASONAL HIGH WATER TABLE.
Method Used: / r
Depth Observed standing in obs.hole: V61a, Depth 10 5011 a19111N:
Depth to weeping from side of obs.hole:' -_-_-- I!r, 'Oroutidwuler Adjustment,—
Index Well## Reading Date: Index Well level Adj,factor,,,,,,,,,,— A41.dr(�Untlwater UVel
Observation C'
Holc##
Depth of Perc C52-
Time at 6"
(�
Start Pre-soak Time @ if •"-" Time(9"-6") f
End Pre-soak. (j SDI v1' 1/ li
LRate Min./Inch
Site Suitability Assessment: Site l'asseil— 5itg Failed: ` Additional Testing Needed
Original; Public Health Division Observation Hole Data To Be Coinp[cted on Back-----------
***1f percolation test is to be conducted Witilill 100' of wetland,yoll nwSt first Uotlfy tllc.
Barnstable Conservation Divisio11 at least olle (1) Week prior to begQlAll. ing.
Q:\S CPTIC\PERC FORM.DOC
DEEROBSERVATION HOLE, LOG
Depth from Soil 1-I062on Soil Texture )bole#
re
Surface(in.) Soil Color Soil• Other
(USDA).. (Munsell) Mottlin
g (Structure,Stones;Boulders,
r Con istene % ravel
Ct
DEEP OBSERVATION HOLE LOG
Depth from Soil horizon Hole#_
Surface(in.) Soil Texture Soil Color �,Soil, +� • O tetl r
(USDA) i' 1'• `
(Mansell) Mottling (Structure,Stones,Boulders.
Consis enc %Gravel
r^
DEE'P ®BSERVATr®1�HOLEDepth from Soil Horizon LOG Dole#
Surface(in.} Soil Texture 5011 Color --
i (USDA) (Munsell Soil Other
;! ) Mottling (Structure,Stones,Boulders.
t Consi
_ ste Icyy%amvel_
-------------
t
r
]DEEP OBSERVATION IDOL LOG ;t
Depth from •LSoil Horizon Soil Texture
#
Surface(in.), a Soil Color soil Other
r
: — •(USDA) :: ,(Mansell) Mottling" (Structure,Stones;Boulders,
Consistency.26 Orav-- --Pl�-
i
h /
r
Flood rnsurance Rate Man•
Above 500 year flood boundary No_ Yes Z
Within 500year boundary No Yes_,'
Within 100year flood boundary No� Yes .
wept➢l o➢1VTtatettrally �ccuflrrfln�ff�ea vious iVlaterial
Does at least four feet of naturally occurring pervious material exist in all areas observed.throu hout
area proposed for the soil g the
P P e otl absorption system. a47 ( } 1
„ If not, what is the depth of naturally occurring per lows materiall
Ceictl cation , X
I certify that on (date)I have passed the soil evaluator examination_approved by the
Department of Environmental Protection and that the! above analy.-is was perfor'iI by me consistent with
the required t g rtise and'experience described in �M CMR 15.017.
Signature � ^ Da
to _ /
Q:1S,BPTfC\PF-RCFORM.DOC -
TOWN O BARNSTABLE
LOCATION d e SEWAGE
VILLAGE 61ef,v, ASSESSOR'S MAP&PARCEL /VO l US"_
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) d ��/ �✓� (size)
NO. OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE: d
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
F : LA
t a�S
t2 2-
�-X-0"
,
No. 20/d / l0 " Fee Cif✓ a
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftplication for bisposal *pstrm Constr "coon 3dermit
Application for a Permit to Construct( ) Repair( ) Upgrade(4 Abandon( ) Complete System ❑Individual Components
Location Address or Lot No. 39 -tit Xni1 &if c_ e OwneF's Name,Address and Teel.No.
alrq
Assessor's Map/Parcel �p -`�YoZg�S^� 3 Mrt
Installer's Name,Address,and Tel.No. Apr `16 Designer's Name,Address,and Tel.No. 51-19' .36VL s)
ys1►�1t t`Rc0 • 6SAi!)sjAh0_-V.,V? 436wn dtde Ej'ir>ev^,ir' ,Trx- F3.9At 54.
Type of Building:
Dwelling No.of Bedrooms Lot Size wg / sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided 5r gpd
Plan Date ae, aG/() Number of sheets Revision Date
Title
Size of Septic Tank i 5 op -1 O Type of S.A.S. '2- O i 710
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and m ' tenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environm al de and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Healt .
Sign Date /C 7
Application Approved by Date o
Application Disapproved by Date
for the following reasons
Permit No. .9010 Date Issued l o O
No. 0 /V / �U " Fee �U(J_-"'
THE COMMONWEALTH•OF MASSACHUSETTS
Entered in computer: V
PUBLIC HEALTH DIVISION - TOWN'OF BARNSTABLE, MASSACHUSETTS Yes
t 01ppIication for 33is " sat 6" stem Con
hermit
Application for a Permit to Construct( ) Repair( ) Upgrade(/) Abandon( ) ❑Individual Components
Location Address or Lot No.a 3y (�t)eo r)r)6 41l r Cr - Owner's Name,Address,and Tel.No. j
c 1c.+c�ille Ph;l�p 6iPt'J� a34/�•iulno�ifL
Assessor's Map/Parcel I D /O �_ Vas,_ 9 9 3
Installer's Name,Address,and Tel.No. (�Of�i(q +r I tJ4 Designer's Name,Address,and Tel.No. 'g'g V'-y�
ys l r t�ta5 pr5tz�n5�}i lls, t14 c� v E �n�er,' ,,crx
- 93949
arm G?ac
Type of Building:
j Dwelling No.of Bedrooms S Lot Size KrQ �/ _sq.ft. Garbage Grinder( )
i Other Type of Building No.of Persons Showers( ) Cafeteria( )
j Other Fixtures
Design Flow(min.required) Sy gpd Design flow provided gpd
,w Pl n' Date xqc)h&i S�Lo Number of sheets_ / Revision Date r`---
Title /.'I (/-5 A,,l
.Size of Septic Tank I 5'cjn S,,vV 14-1 O Type of S.A.S. �• 4,14 6e
Description of Soil
i
Nature of Repairs or Alterations(Answer when applicable)
i
i Date last inspected:
I Agreement: p
The undersigned agrees to ensure the constructionintenance of the afore described onmsite sewage disposal system in
accordance with the provisions of Title 5 of the EnvironmeA�al�G62and not to place the,system in operation until a Certificate of
Compliance has been issued by this Board of Healt
i Sign / Date 4 -7 1jew
Application Approved by Date /
Application Disapproved by Date
for the following reasons
Permit No. X2 o/U — ��/y Date Issued
r - -----------•- ----- -=- - --------- --- - = - - - -----------------
r
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired((X Upgraded( )
Abandoned( )by &r eG rl,4 " e_ kln _r1 C_
at cg 3 y W•t a n nr, !A^►Nellie - has been constructed in accordance
with the provisions oi+f��Title
p@5 and thefor Disposal System Construction Permit No. U'u—�/�lI dated l D by
Installer&!JG ti't C{i�nc+ruLF n t� �� Designer jpwn
#bedrooms Approved design flow 5 U gpd
The issuance of jhis p mit shall not be construed as a guarantee that the system 1 eon as de gned.
Date d Inspector
No. Q U — in Fee UO
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair(k,,< Upgrade( ) Abandon( )
System located at a 3 q f(,�ttQ nc, Cl i r'c r
i
and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 permit
Date /u — 7—/J Approved by '✓�n�
NOV-03-2010 08:38 From:BORTOLOTTI 'uK'' V-7 084289399 To:15087906304 P.1/1 x.!
FROM :dawn+ cape en9i+cerin9 inc FAX NO. :15083629M Nov. 02 2010 03:1.5PM P2
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soptlo syme-.0 at. /�/I,O+,�/p L.+e/ hFL onn dc!gl�l1T C�zSW�I.by
67441 dkLtrc�
T certify Thal tbA geTtic UstM refarmraeed ,abovr.WR9 irista-fl,ed 4-1,011681.17 t11:•CO"P9 YC
rho drys gty which°)ILLY inr..lsadc LuigOr. �tpruved Q,tirsnpn� ;3itcl�. s 17.t�r�a1 rclxzcali.v>x of Ltx
cl:istrilintim box Se l%c tit .- ' � � ir►ft rrr�
I cerfilly lhsr. t41d rpric ys rtrf�►.'enc l 131)ve VP'tr9 inSf lled With TILIjOt (AUl n7;e;+ (i.e
aTs11 fytzti=nc�aCtu r�ltiii�e av u of the l? ,titate S OT B J oc;t�l��t�WWat on, plfw xvision'
' or
of Itld '�P,pIiG Sys t• )
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DAN1EL�
OJALA
T{Tri7��,r1Kulats��w,)
No,48602
fl-/1-0 ss'(Mn,.
;1 w1�"cIJ11I1 Hc:l'+3)
�T RL cN ";,g
PIL
.�� 1Lanll}u'�+:priiJi')c61$+�n,(:rfiricaflox FU,A1 i:1fr04�{10�:
ALL SYSTEM SHALL
OMPONE
SYSTEM PROFILE MARKED WITHCMAGNETIC TAPE OR BE NOTES a .�
COMPARABLE MEANS FOR FUTURE LOCATION. Sou h �o N
PROVIDE WATERTIGHT 20" DIAM. (NOT TO SCALE) 1. DATUM IS APPROX. NGVD
'i ACCESS COVERS TO WITHIN 6" OF FIN. GRADE �, �St•
TOP FOUND. EL. XX.X' PROVfDE INSPECTION PORT TO WITHIN 3" OF FINAL GRADE 2. MUNICIPAL WATER IS EXISTING
3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.
29.3' MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRE OVER SYSTEM 29•5 trey
MIN. B" oIAM. 4. DESIGN LOADING FOR ALL PROPOSED PRECAST4L
0°
PRECAST H-10 UNITS TO BE AASHO H-]•Q
RISERS
i PROP. TEE PIPES EO PVC 2" DOUBLE l HED PEASTONE 5. PIPE JOINTS TO BE MADE WATERTIGHT. o��0
y: * �r PIPES LEVEL 1ST 2 OR GEOTEXTIL� FABRIC a 9
30.2 PROPOSED+ I 27.0' a
*29.3 10" 1500 GAL H-10 14" y V6�TMONSTRUC110N DETAILS TO BE IN ACCORDANCE `� O
27.25' TEE SEPTIC TANK TEE \__27.0'
0 0 0 0 0 0 0 310 CMR 15.000 (TITLE V.) ) -
> GAS BAFFLE �?o Joao^o°o 0 26.25 c / OCu
2' 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND
r : 4' UQ. LEVEL (ACME OR EQUAL) '; 26.43' 26.26' $ o 24.25' NOT TO BE USED FOR LOT LINE STAKING OR ANY
o0 A OTHER PURPOSE.
..;. _ a . .r.- :: .• .•,: .. 6" MIN. SUMP I
•••� ~ 0°o°,o'°,°o'o�°o�.'+ °o'o�c�c�°o''o�c°+�°o��'n�:°+'n�'o�°°o'°o'° 12" MIN. TNT. DIM. H-20 300 INFILTRATORS
8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. antucket
6" CRUSHED STONE OR MECHANICAL 3/4" TO 1 1/2 DOUBLE WASHED STONE 9. COMPONENTS NOT TO BE BACKFILLED OR Sound
COMPACTION. (15.221 (21) CONCEALED WITHOUT INSPECTION BY BOARD OF
( 3.6% SLOPE) ( 8 % SLOPE) ( 1 % SLOPE) OVERALL DIMENSIONS TO OUTSIDE OF STONE: 53.7' X 10.25' 6' OFALTH HEALTHD PERMISSION OBTAINED FROM BOARD
FOR LONGEST RUN
10. CONTRACTOR SHALL BE RESPONSIBLE FOR LOCUS MAP
40' LEACHING CALLING DIGSAFE (1-888-344'-7233) AND
FOUNDATION 57, SEPTIC TANK 8 D BOX 3 FACILITY VERIFYING THE LOCATION OF ALL UNDERGROUND & NOT TO SCALE
OVERHEAD UTILITIES PRIOR TO, COMMENCEMENT OF
*THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL BOTTOM TH-1 & TH-2 WORK.
UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS NO GROUNDWATER FOUND 18.5' ASSESSORS MAP 140 PARCEL 105
11. ANY UNSUITABLE MATERIAL ENCOUNTERED
PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM
SHALL BE REMOVED 5' BENEATH AND AROUND 11-IE
PROPOSED LEACHING FACILITY.!
12. EXISTING LEACHING FACILI-Y SHALL BE PUMPED
AND REMOVED OR PUMPED AND FILLED WITH CLEAN
LEGEND SAND.
99 - EXISTING CONTOUR
X 99.1 EXIST. SPOT ELEV.
99 PROPOSED CONTOUR
BENCH MARK - CORNER OF 29.84 SYSTEM DESIGN:
[98.41 PROPOSED SPOT EL BULKHEAD ON WOOD EL. = 31.0
TH1 GARBAGE DISPOSER IS NOT ALLOWED
TEST HOLE
137.79 \
X DESIGN FLOW: 5 BEDROOMS ® 110 GPD = 550 GPD
�-X X x 29.81 + -
2� SLOPE OF GROUND ` USE A 550 GPD DESIGN FLOW
UTILITY POLE \\
N yo C•0•x ��, �, \ SEPTIC TANK: 550 GPD (2) = 1100
FIRE HYDRANT o 2 .05
USE 1500 GAL H-10 SEPTIC TANK
NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING X 9.15 '� 1.4 �' \
X O LOT 141
10' 4 INVERT 0 15,799 t SF LEACHING:
30.14
14" OAK X �8, X .2 EL. 30.2 Z SIDES: 2 (53.7 + 10.25) 1.85 (.74) = 175 GPD
TEST HOLE LOGS 11 2 X 5 \ Z BOTTOM 53.7 x 10.25 (.74) = 407 GPD
16" oA \
ENGINEER: DANIEL A. OJALA, PE, SE t� 29. 4 DWEWNGBR
X 6 8 EAST. 5 \OAR NF TOTAL: 786 S.F. 582 GPD
�3 �
WITNESS: DAVID W. STANTON, RS "o TOP FNDN. \ T/FS \ USE (7) H-20 3050 INFILTRATORS WITH
SEPTEMBER 29, 2010 9 14" OAK X 0 22 = 32.5' \ \ 2' STONE AT ENDS AND 3' AT SIDES
DATE' o DECK \ �30.20
PERC. RATE = < 2 MIN/INCH o 5 x 29 6
C.
CLASS I SOILS p# 13072 INVERT
X 0.16 EL29.35' - W W W W NN. \ \ \
30.20
ELEV. ELEV. X 0. 29 3 29.Fs 15 62 0.5708 \ \
0„ 4 29.5' off 29.5' 29 1 11 30.31 1.46 APPROVED DATE BOARD OF HEALTH MA
A A 14" OAK PAVED DRIVE
LS LS 29.9 �� 81 w 0 0.330.37
0
10YR 4/2 10YR 4/2 X 3 .01 `-� _ 30.22
6" 6" 14" OAK \ 30.94
B B X29.07 X2996 \ TITLE 5 SITE PLAN
LS LS X 29.98
OF
30.36
36" 10YR 5/6 26 5' 36" 10YR 5/6 26.5' W 157.00' 234 WIANNO CIRCLE
CESSPOOL?
OSTERVILLE
C C PREPARED FOR
PERC
BORTOLOTTI CONSTRUCTION/REILLY
MS MS I
OCTOBER 5, 2010
2.5Y 7/4 2.5Y 7/4
�OH of MgsS H OF MASS off 508-362-4541
�
fax 508-362-9880 o DANIEL yGm DANIELA. �� downcope.com
o A. OJALA
OJALA CIVIL CD 40980 o. 2 down cope engineering MC.
132" 18.5' 132" 18.5' olo.
{ pt�,s ,0 G, ° `` civil engineers
" - surveyors
E land ors
NO GROUNDWATER ENCOUNTERED Scale: 1"= 20' �p,S- �t� _ ON y
939 Main Street ( R to 6A)
DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675
.> 0-2 > 0 10 20 30 40 50 FEET 10-211.DWG(SBO)