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0261 WIANNO CIRCLE - Health
261 Wianno Circle vsterville r = 140— 1,04 N ,, , ry 3 ° lr • - ° o 3 r. s .n I n a a o No. Fee 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye— PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipplitation for Disposal *pstem Cunstruttion Permit Application for a Permit to Construct( ) Repair%c Upgrade( ) Abandon( ) [:]Complete System ❑Individual Components Location Address or Lot No.246 W R 11nO C 19/. O S i O%J Me Owner's Name,Address„and Tel.No. Assessor's Map/Parcel J y O 1 O y Lo cAs + CR o i l.t N "T"v R rt,1 t Installer's Name,Address,and Tel.No.jD$-LA I l - S$-1'1 Designer's Name,Address,and Tel.No. 3(o3 w�,,�es 'rk-nk St,,jnA y0�jz w,%sna OL(D(o4 Type of Building: ChI1<f G� Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd 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) zh&4,N11 NXC L,3 !)D 3 1416 B-,z.X, Coou�_ i TrS I� Nt 1 00-TIJ fee Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environm,41 Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of alth. o Signed (i Date / _ ^ 2 1 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. .�� Date Issued � . No "�i/ti/ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Y es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppliLation for NspoSal *pstrm Construction 3Ertttlt Application for a Permit to Construct( ) Repair(�) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.2b1 W to MO Cl i:. 0 S i<R,J ltl• Owner's Name,Address,and Tel.No. Assessor's Map/Parcel } I H 0 0 y � ,� LV GAS,.S + C'X%<t_1 N —r\j e'ZTlo�-1 Installer's Name,Address,and Tel.No.,j pt)-1-j"t l ' $"1`1 Designer's Name,Address,and Tel.No. 3c�3 �W1„��s P,�-na• Sc.,i-ta y�a�i�,.,.�na ©;c��y Type of Building: A/11 G Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil r Nature of Repairs or Alterations(Answer when applicable), 1"l\s4,N11 NEL.a IJ ��ia BQX, tD, / Cv✓z(1. 4 AZ<<Sc,c i��MJ 7,vid ' TM SlA 11 N tIJ O Q-01—i I t It Date last inspected: s=^ Agreement: ,. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage dispos system in accordance with the provisions of Title 5 of the Environmen l,.Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of HHeealth.,- " y Signed G, AC�� Date _ D f Application Approved by ....; ,, � Date / f Application Disapproved by -Date for the following reasons Permit No. ,- a/ ' '33-5 Date Issued / y THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS CCrttficatP Of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded(" ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No )—_V3dated ( i' Installer Designer #bedrooms Approved design flow gpd =r The issuance of this permit.shall not be constr ued as a guarantee that the system will°'function as design&.. �`-, Date (firf Inspectors. No. ,--,A.(l--V 'F Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS I DlstlOe-at .6- pBtem Construction j3Prutlt Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System`located at c^ f�'l )�d�t�.c'S C" . Ali— 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. r Provided:Construction must be co�pleted within three years of the date of this permit. Date s I 1 7 IA Approved 6y , TOWN OF BARNSTABLE LOCATION Gu',Aww O -S. SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL ItwAfL �S NAME&PHONE NO.'j,' SEPTIC TANK CAPACITY _`S®O LEACHING FACILITY.(type) t— (size) a - V�/ e✓� NO.OF BEDROOMS OWNER a,®.r �r y 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 FURNISHED BY'l e\ t-'-, �.✓�ems`��C\ : .� t f� ('� 'U o�O l •W.q��.r� � Q r�v�GcvQc,� y Est Cr® t 5 Commonwealth of Massachusetts o Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Wianno Circle Property Address Joan Krauss Owner Owner's Name information is required for Osterville MA 02655 October 20, 2011 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 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 a P.O. Box 371 Company Address Sandwich MA 02563 — 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 15.000). The system:. Passes ❑ Conditionally Passes Fails �^ F1 Needs Further Evaluation by the Local Approving Authority i -, October 24, 2011 mow. Inspector's Signature Date o '„ 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. I t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 261 Wianno Circle Property Address Joan Krauss Owner Owner's Name information is required for Osteryille MA 02655 October 20, 2011 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", "non or"not determined" (Y, N D) for the following statements. If"not ` determined," please explain. The septic tank is metal and over 20 years old"or a septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltrati or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replac d with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if i is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less han 20 years old is available. ❑ Y ❑ N ❑ ND (Ex ain below): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 , • 4_ Commonwealth of Massachusetts s Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Wianno Circle Property Address Joan Krauss Owner Owner's Name information is required for Osterville MA 02655 October 20 2011 —_ _ —_� every page. City/Town State• Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replac/dEl Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed Y ❑ N ❑ ND (Explain below): distribution box is leveled 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/heh, of Health: ❑ Conditions exist which require furthen by the Board of Health in order to determine if, the system is failing to protect publicfety or the environment. 1. System will pass unless Board determines in accordance with 310 CMR 15.303(1)(b)that the system is notng 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-69/08 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 261 Wianno Circle Property Address Joan Krauss Owner Owner's Name information is required for Osterville MA 02655-- October 20, 2011 — ----- 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 and SAS d the SAS.-is within a Zone 1 of a public water supply. ❑ The system has aseptic tank and S and the SAS is within 50 feet of a private water ' supply well. ❑ The system has a septic tank and SAS an 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 nalysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the pregsj� nce of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no o her 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 Stickup 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 Ell due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-09/08 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Wianno Circle Property Address Joan Krauss Owner Owner's Name information is required for Osterville MA 02655 October 20, 2011 , every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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 aZone 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.] - t ❑ ® 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 w/apped et of a surface drinking water supply ❑ the system is wet of a tributary to a surface drinking water supply ❑ the system is lnitrogen sensitive area (Interim Wellhead Protection EJ Area—IWPA) d Zone 11 of a public water supply well If you have answered "yes"to any quection E the system is considered a significant threat, or answered "yes" in Section D abovsystem 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 rg.ginnni office of the Department, t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Wianno Circle Property Address Joan Krauss Owner Owner's Name information is required for Osterville MA 02655 October 20, 2011 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 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 261 Wianno Circle Property Address Joan Krauss Owner Owner's Name information is required for Osterville MA 02655 October 20, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: . Number of current residents: 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 2009= 178 GPD* 9 ( Y g {gpd)) 2010= 288 GPD Detail_ *High water usage during summer months due to irrigation. Sump pump? ❑ Yes 0 No Last date of occupancy: Current ' Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Ganons per day(gpd) Basis of design flow(seats/persons/sq.ft., et Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ .No Non-sanitary waste discharged to a Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Forth: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 261 Wianno Circle Property Address Joan Krauss Owner Owner's Name information is required for Osterville MA 02655 October 20, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: bate Other(describe below): General Information Pumping Records: Source of information: Ready Rooter records: Pumped Sept. 2009 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons w How was quantity pumped determined? Reason for pumping: Type of System: r ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. _ ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 8 r Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 261 Wianno Circle Property Address Joan Krauss Owner Owner's Name information is required for Osterville MA 02655 October 20, 2011 - every page. 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: System installed approx.,1981. Age of home. No records on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 214.1 Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A 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: 11.5'X 5'X 5.5' 1500 gallons Sludge depth: 2" t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM r 261 Wianno Circle " Property Address Joan Krauss Owner Owner's Name information is Ostefville MA 02655 October 20, 2011 required for _ every page. 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 36,E Scum thickness 211 $1@ Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12,E 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 PVC tee and outlet concrete baffle in place. Recommend replacement of outlet baffle due to corrosion of concrete. Liquid level is at outlet invert. Risers bring covers within 6",of grade. 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 op of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09108 Title 5 Official Inspection Forth: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 y 261 Wianno Circle Property Address Joan Krauss Owner Owner's Name information is required for Osterville MA 02655 October 20+ 2011 every page. CityTrown 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 [� iberglass ❑ polyethylene ❑ other(explain): f Dimensions: Capacity: r J' gallons Design Flow: - gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 i Commonwealth of Massachusetts 13- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Wianno Circle Property Address Joan Krauss Owner Owner's Name information is Osterville MA 02655 October 20, 2011 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): 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.): One inlet, two outlets. Equal flow. No solids carryover. No'high water staining over outlet inverts. D Box is under brick patio w/riser within 6"of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: El Yes ❑ No Comments(note condition of pump cha er, condition of pumps and appurtenances, etc.): t Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 261 Wianno Circle Property Address Joan Krauss Owner Owner's Name information is required for Osterville MA 02655 October 20, 2011 _._._ every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2-6'X4'w/stone ❑ 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.); #1 Leach pit: Empty at time of inspection. Leach pit#2: Liquid level 2' below invert. No sign of past hydraulic failure in either pit. Cesspools(cesspool must be pumped as part of inspection) (locate on site,plan): Number and configuration Depth—top of liquid tdinlet invert Depth of solids layer a Depth of scum layer A Dimensions of cesspool Materials of construction w Indication of groundwater inflow ❑ Yes ❑ No t5ins•09hJ8 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Wianno Circle Property Address Joan Krauss Owner Owner's Name information is required for Osterville MA 02655 October 20, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, igns of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•091[G Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 261 Wianno Circle Property Address Joan Krauss Owner Owner's Name information is Osterville MA 02655 October 20,2011 required for r State Zip Code Date of Inspection every page. Cflyrrown D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t � 153 O 4 tSins•09/08 Title 5 official Inspectionm Form:Subsutface Sewage(Ymposal Syst -Page 15 of 15 R Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Wianno Circle Property Address Joan Krauss Owner Owner's Name information is Osterville MA 02655 October 20, 2011 . required for every page. CityTTown 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: pate ® 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: No ground water intrusion into dry leach pit.Accessed local ground water contours and topo mapping. - Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 261 Wianno Circle Property Address Joan Krauss Owner Owner's Name information is required for Osterville MA 02655 October 20, 2011 every page. City/Town 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 . r ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file a t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No.. d.'_./z.? F�$ ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' UUv..N...........OF......I�/S► .S?A... Gu�'" ------------------------------------- Appliration for Uwvoiia1 .irk C�owitru.rtion amit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: r ................. __s !_!� �C �---•----.......__....._.._.......---•------- Location-Address or Lot No. o.�_s------•---------------•------- -- --...._©S .......................'�/e� ez...... Ownern Address ...... ...... %�!'l��_P........ ....................... ....... Installer Address dType of Building Size Lot_J6_!2'e0._______.Sq. feet Dwelling—No. of Bedrooms____.__._:`7______________________________Expansion Attic (v) Garbage Grinder (� '4 Other—Type of Building k/.4010._____._._ No. of persons____________________________ Showers — Cafeteria A., Other fixtures -------------------------------- - W Design Flow............................................gallons per person per day. Total daily flow.......................•....................gallons. W Septic Tank—Liquid capacity/Z-So__.gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No_____________________ Width.................... Total Length_.______.___________ Total leaching area.................... ft. Seepage Pit No._/�--�_____ Diameter____8._..___.._.. Depth below inlet._�S-_.�__________. Total leaching area_�L�Sf_(A. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by.......ZkJ ....... �___.__...______________________ Date___s�/el. �'______-- Test Pit No. i_��___minutes per inch Depth of Test Pit....�3-______.__ Depth to ground water_..1�D�u_4'�_.. (i Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water........................ ------------------------------------------••----•-••-------•----••---......................-•••••-•-........................................................ 0 Description of Soil.......C2.- .? ..... -----------7- --/--� ------ ------------ x V ------------------------•-•---------•-------------------------------------------------------...----•-------•--------------------------------...------------------------......._.__....._..-------- W ------------------------------------------------------------------------------------------------------=-------------------------=-------=-----------------------•--------------------------------- U Nature of Repairs or Alterations—Answer when applicable................................................................................................. --------------------------•--------•-----------------------------------------.-.-_._...............-------•---•-------------------------------------------------•--------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i?TLi; p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance hasd._bUs. Signed by t e board of health. ,. . Date Application Approved By 1 = Date Application Disapproved for the following reasons_________________________________________________________________________________________________________________ ----------------------------••---------------------•------------....----....----------------------------------•---------------------------------•------------------ ---- ............................. Date Permit No......................................................... Issued_--•-- ........................... . Date No... ........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7_7�00VJV...........OF...... ......................................... Appliration for llhipwml Vvr�hk T ustrurtion "amit, V Application is hereby made for a Permit to Construct .( or Repair an Individual Sewage Disposal Sy stem at: 41 ;7—el? 4 .......... ........................................ ................................................................................... 7":----------------- ......--------- L * A,Adress No. Z .... . ....... ........ ....... .. .. .......... ............ ......... Owner 0 Address .................................... ................................................................................. Installer Address F Type of Building Size Sq. feet Dwelling—No. of Bedrooms...........................................Expansion Attic Garbage GriVder 114 Other—Type of Building .... .......... No. of persons._.._............._..__.___. Showers Cafe4eria 44 Other fixtures ------------------------------------------------------------------------------------------------------------------------------------------------------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity/Z.50..gallons Length................ Width-------__-_-___- Diameter._._.._..._..... Depth_.__._...___.... Disposal Trench—No..................... Width_...__.......__..... Total Length......._............ Total leaching area-_______..__.___ ft. / ;�- 2— ft. Seepage Pit No-------------1------- Diameter....19.......... Depth below inlet_.4�.............. Total leaching areaA� Z Other Distribution box Dosing tank 0-4 ) Percolation Test Results Performed by.---__-..(.....;q ......... ............................... Date...2R4�...7.... �--4 O e' Test Pit No. 1_4_4.....minutes per inch Depth of Test Pit.... ...... Depth to ground water.._.A,,....)...0.A............ rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit...._............... Depth to ground water.................._.___. ----------------------------------------------*................**-------------------"---------------------------------- ------*-----------*------- A4 4:AI alm _1> 0 Description of Soil....... .. ......... ................................14,V, .......................... U ............................_1......................................................................................................................................................................... ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable._.__........................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bepn,issued by P.e board of health. Signed....... ......................................I------------------------------------ -------------------------------- Date Application Approved By. ..... ..... .......................... Date Application Disapproved for the following reasons:................................................................................................................ ........................................................................................................................................................................................................ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......✓..... �P:;�6' ..... .... ..........0 F......... .. . .. ............................ (9rdifiratr of Toutphaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by------.... ..........e XALP.e............................................................................................................................ Installer< e� �e at................A���....... ..............4-V. -.4 �!.......................................................................................... ............ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated-............................................... THE ISSUANCE OF THIS CERTIFICATE,SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. I S G( d 4 DATE.......... .... ................................... Inspector... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............OF..... ........................ No.. 14sposal lVark.5 T11mitrurtion famit Permission i 6reby granted..-----. ... ....................Z-1.4 A),R S .......................................................................................... to Construct or Repair an Individual Sewage Disposal System atNo.--- --A,-•-A?...7......... .............A k....... .................. ................................. Street as shown on the application for Disposal Works Construqtjou4ermit No...................... Datedj....................................... ............... . ... ..................................... Boar( i h . ................. DATE...... ........................................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Ie G) C,aA2$ALE IIC> Z 440 a.P.P. G.r/' SEP�RG TAtak ` 44-01Ll970 c) GPp 1 u;� l2 GAL, 5t � TC. 17A,kg_ CT —4 v sr. 60x z � 0 � ipopsAL_ �►t1 V 3E , ��s AQEA = `Z . 150=zoo IF twtta H u -,50V A -z,Zr G/SF 75'U GP Z + PFvP G4P_ r 50 TOAn AaeA.= Z K ` / e lslz = \CIO G Pp 7,; lzyyL. 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