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HomeMy WebLinkAbout0040 WINFIELD LANE - Health r 40' W"infield Lane' Osterville' a I e P 4 t f t i TOWN OF BARNSTABLE LOCATION SEWAGE # VULLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. - SEPTIC TANK CAPACITY _ LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: 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 TOWN OF BARNSTABLE LOCATION `7` d Gt1ii11lel� �/�} s�' SEWAGE.# o7L'df—/7d VELLAGE.' 0 S 1 e rw.-C<< ASSESSOR'S MAP & LOT 10.Z, INSTALLER'S NAME�&PHONE NO. 9. SEPTIC TANK CAPACITY S00 C91 4'i4 /060Gel �61�r17i LEACHING.FACILITY: (type) (size) NO. OF BEDROOMS / (BUILDER OR OWNER �. vel 'l�..• PERMITDATE: O ( COMPLIANCE DATE: :f'.Z3 �" I Separation Distance Between the: Maximum Adjusted Groundwater.Table and Bottom of Leaching Facility Feet Pnvate"Watei Su PP'1Y Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching.facility) ` ' Feet Edge of Wetland and Leaclung Facility(If apy wetlands exist within 300.feet of leaching.facility) ' _ Feet Furnished by 'D cso t2 CY 1 ' l w 39 ,. i J TOWN OF BARNSTABLE LOCATION 7//d Gt///1 i t el� � /6 -SEWAGE # o7Od 1-/'7Z VILLAGE r�-<<L ASSESSOR'S MAP & LOT /02, INSTALLER'S NAME&PHONE NO: - G�I�-f'-G«<���r y L1 I '5 , SEPTIC TANK CAPACITY /SDO G"�� �.ii /000Gel"`��`0 e6/f►r,3ir�2 e10�3 CS� LEACHING FACILITY: (type) f-/ac,.� a,P� (size) NO. OF BEDROOMS 1 6 BUILDER OR OWNER PERMITDATE: 1-1,9/eCH o'er O 1 COMPLIANCE DATE: -5-' Z 3 �' r Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Welland Leaching Facility (If any wells exist on--site or within 2W feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r� OF f A 3 3 t'i a a r e � e• * n M LOCATION SEWAGE PERMIT NO. VILLAGE I N S T A LLER'S NAME i ADDRESS J`. 2 S U I L D E R OA OWNER I)o � �� � � � DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � If J w 5 f r THE COMMONWEALTH OF MASSACHUSETTS (�— E®AR® OF HEALTH � �}D ..........OF...../..6/-.t.'.4iSJ ................................... �e pLW p irativit for %yusal Works Tonstrurtinrt rrutit 41.A\)- Appli tion is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal Syst o t'on-Address or Lot No. .�+ ner e— Address � Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling�No. of Bedrooms............................................Expansion Attic ( ) Garl*ge Grinder ( ) C14 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures --------••••----•-•----•--••---• - w Design Flow.............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by............................ ................................ Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--_-_-_______-__-----__- G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------.................. - . ------- - ---- - O Description of Soil........ ................ x Uw ................................................ Nature of ReFairs or Alterations Answer wen applicable__.._ ' ���..--/. . .. ..... ........ _i Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL 12 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued y t bAu of health y Signed . •. -----•... -----•---•- ----------------•-� J Date Application Approved BY - - ---------------•-- •--------•-- ---------- ��` 4 Date Application Disapproved for t e following reasons:----•-------------------------------------•-----------------------------.-----•--------- ------------......... ...............................................................................................--••-•----••-•--••••-•-••••••••--••••••-•••••-•-•----•-••••••--•-------••----•••--------------••-...... Date 5�5 ... Permit No. 4 0.3.......................... Issued-----------------------------------5............... Date I No..`�5� .L FEs.. `ties< .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTF-I - € . ............OF..... Applirntion for Disposal Works Tonotrnrtion Vprrmit Application is hereby made for a.Permit to Construct ( ) or Repair ( ` an Individual Sewage Disposal System at .....:. ......i„/f._.:.d......`....::.. •__. ::....Jt.. ..... .._::._"Y_'f l_.._ ; ...•......-•---•---•--.•....................................... ............................. ^r en ocation•Address or Lot No. e 5�'r •� j f* '•d.-in .... - ° :s. ••........................•-•••••.......... ....-• •--- ¢caner Address IW1 ' _s�S 6f�'. @'.r ytJ , 2..P�.... h¢•-• -A `F �* •. .................................................. ----------------------•-----•------•--•--- Installer Address Type of Building', Size Lot............................Sq. feet U Dwelling, o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder _( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) - Cafeteria ( ) Other fixtures .......................---....................................................................................................... .... WDesign Flow.............................................gallons per person per day. Total daily flow-------_-__.____.-_______:__:___._.._;.___.gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth...:__:,_____--. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area_.:_._:'.........:..sq. ft. I Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area.....................Sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results . Performed by.......................................................................... Date........................................ Test Pit No. L..::...........minutes per inch Depth of Test Pit.................... Depth to ground water......_.______________-. ( Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 4' p4 rd x. Description of Soil •%= _. -- OM --••--••--•-------•--•-------------•-•-------------- ----•----•-------------•-••-- .' W ............................................................... r U Nature of Repairs or Alterations—Answer when applicable ��`"". = � � E^ ' ........... dG[l�l/T,t -•-------��....... .. ` . _r •.... � ZY'U..S..�r�tS t... ,.z Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIThE}' 5 of the State Sanitary Code- The undersigned further agrees not to place the system in operation until a.Certificate of Compliance has been issued by toe board of health, f Signed. .. s, ..e J._3t{_ ._.._.. 'Y_i _.._ y___ '�________________ ___ __ _Y !ra.f '4` Date Apphcarion Approved By _._.__ Date Application Disapproved for th following reasons---- -------------•--=------•------•------------------------....-------•---------••--••-....................... ................................................................................................................................................................................................------- Date Permit No.................. Issued ---••---•••_•----• ......... ...................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f A wntifirtttr of Tontpliattrr J n T LH I IS` 0 CERTIFY;'That the jndividual Sewage Disposal System constructed ( ) or Repaired � •' by:. ----------------- ----......... .--------•-••......-•••-•-----••-- �� a ` t Installer__. $ > ,+ s Ir I N J„ / --- I --- _ df'� e.j„� .......................................... has been installed in ac - dance with the provisions of TITIF 5 of The State Sanitary Code as described in the PP P g-`--�'- application for Disposal Works Construction Permit No..-___��.::��D�_____________. dated__..._.___ ._.!- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED, AS'-A GUARANTEE TIiAT THE.,....-..� SYSTEM WILL FUNCTION -SATISFACTORY. DATE.............. _ t....--..�j.................................. Inspector........ N. ........ .......................... THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH .. r'..x f tea' . OF.....':.r N No......................... r f FEE...:'.. .. ..... Disposal�Works TonotrudionVrrmit ,'it ./ Permission is hereby granted = -• = --- =4--•...•- �`g ==` `; .............................. to Constru ( ) or Repair Individual Sewage Disposal System s r , . at 0-....4,tr . v .. .............. 'F •---------•-- --- !` Stree ��.'�- as shown on the application for Disposal Works Construction Permit ......... _ at_d . . ............................. Al - _ •..................... ............... .............................................. Board of Health DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON - - NEW IQwN QF BARNSTABLE 4:.� SEWAGE#.: �d�'/.�/CS „ LOCATION - l6 "`lCt Z� ` ASSESSOR'S MAP &LOT l YII LiASE INSTALLER'S NAME 8�PHONE NO.� is s t(a=�—� � -- r SEPTIC TANK CAPACITY i S size LEACHING FACII:Im (type) rQ``` F�l o ej C (: ) . NO OF BEDROOMS ° BUILD ER OR OWNER Z3 PERIvIITDATE: /yA,QCr1 COMPLIANCE Separation Distance Between the: Feet Maximum Add usted Groundwater Table and Bottom of Leaching Facility' g h, we11s exist PrivateVatei Supply Well and Leaehin Facility- f any Feet on sitC or wi'thin'200 feet of leaching facility) �... Edge of Wetland and Leaching Facility(Zf any weYlanda exist Feet within3QO feet of leaching facility) Furnished by I. .. .. Y Ll ,h t le a 17 P C ry�.72 i 76 � os�GT. �9� : r _ _ No. �11r9� ! s Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for &!5pogal bpgtem Congtruction permit Application for a Permit to Construct( )Repair(0')Upgrade(y'�Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Lj 0 W,; 7,e L.5 b Q,,t.0 Owner's Name,Address and Tel.No. Assessor's Map/Parcel S z 2.v i 1 I F ,` ` Agln2 Installer's yNName,Address,and Tel.No. Designer's Name,Address and Tel.No. 8Z mow s;. ts�+c. __ 93Q 4�A �►., s�, Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(,VA Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow L/y0 gallons per day. Calculated daily flow gallons. Plan Date 7-4.4; .g- 200/ Number of sheets Revision Date Title Size of Septic Tank /Sao Gag/< Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)�SYdA�rz 091 or"D%Art Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu by this Board of a th. A,r Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. 4,Q e Date Issued .L�4� -1Ve" �1/ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC'HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Rpplication for Miqu ar *p6tem Construction Permit Application for a Permit to Construct( )Repair(05 Upgrade((Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. t-t © W � Owner's Name,Address and Tel.No. � �el� i��a�c Assessor's Map/Parcel v S "a ` Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. aii_ d �SruQ tkACC.II (Ar2 v, s j, r ssa�� C) Li Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(Ale) Other Type of Building No.of Per§'ons Showers( ) Cafeteria( ) Other Fixtures Design Flow /l5/o gallons per day. Calculated daily flow gallons. Plan Date 35L1 , moo I Number of sheets Revision Date Title •� r Size of Septic Tank J.SQ O 60/. Type of S.A.S -/0 Description of Soil Nature of Repairs or Alterations(Answer when applicable) fiot/c7cyrr 0)]orlalm Date last inspected: Agreement: _ The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of J�e,�th. Signed-7S wr.l O.GGa GG�`I5S Date Application Approved by 4e—ee gg y ea..y Date 11 Application Disapproved for the following reasons X Permit No. o7 04 Date Issued - 2.&tv 1f --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (tertificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( !� Abandoned( )by rri1!!�.1/,'!�, at _ i/Q 7rAL,On lc has been constructed in accordance with the provisions of Title 5 and th for Disposal System Construction Permit No aOO/./09rdlated -'T X w e v Installer' Gr G Designer The issuance of this permit sh ll not be construed as a guarantee that the syste 11 f ti s desig d e Dat �Z 3 �a / Inspector _ / —� r . d ------------------------- No. 20,0,1-' 17,:1f, Fee 'xF! THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS •------ 1=fgpogaf*p5tem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(P-1 Abandon( ) System located at _40 Wt✓L_r,ctz, L) (Ao, r 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 permit. Date: Approved by f/ . �-�' -��f U / f Commonwealth of Massachusetts Title 5 Official Inspection For . fh AR11STAB E Not for Voluntary Assessments ^M Subsurface Sewage Disposal System Form 203 NO 30 110: 47 Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification //G /off i !ISiO�d 1. Property Information: 40 Winfield Lane, Osterville, MA 02055 Property Address Fred & Diana Uehlein Owner's Name 40 Winfield Lane Owner's Address Osterville MA 02655 City/Town State.. Zip Code Date of Inspection: 10-31-05 Date 2. Inspector. Paul McDowell Name of Inspector The Building Inspector of America Company Name 2 Brookside Circle Company Address Wilbraham MA 01095-2102 Cityrrown State Zip Code 1-800-626-4408 „ Telephone Number Certification Statement: 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 Need Furth r Evaluatio .by the Local pproving Authority 10-31-05 Insp ignat Paul ;ell PMAco Date The system inspectorshaTf submit 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. 10325.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 1 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments ;M Sv Subsurface Sewage Disposal System Form A. Certification (cont.) 40 Winfield Lane Property Address OsterVille MA 02655 City/Town State Zip Code Fred & Diana Uehlein 10-31-05 Owner's Name Date of Inspection 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 y Passes: N/A ❑ 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: 10325.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 2 Commonwealth of Massachusetts Y Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'G M A. Certification (cont.) 40 Winfield Lane Property Address Osterville MA 02655 City/Town State Zip Code Fred & Diana Uehlein 10-31-05 Owner's Name Date of Inspection B) System Conditionally Passes(cont.): N/A ❑ 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: C) Further Evaluation is Required by the Board of Health: N/A ❑ 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 10325.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 3 ti I Commonwealth of Massachusetts v Title 5 Official Inspection Form Not for Voluntary Assessments /4„M yV6y Subsurface Sewage Disposal System Form A. Certification (cont.) 40 Winfield Lane Property Address Osterville MA 02655 City/Town State Zip Code Fred & Diana Uehlein 10-31-05 Owners Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): N/A 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 nitr ogen 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: 10325.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 4 of 4 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ,M Subsurface Sewage Disposal System Form A. Certification (cont.) 40 Winfield Lane Property Address Osterville MA 02655 City/Town State Zip Code Fred & Diana Uehlein 10-31-05 Owner's Name Date of Inspection D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ❑N/A Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow 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. ❑ ❑ N/A Any portion of cesspool or privy is within 100 feet of-.a surface water supply or tributary to a surface water supply. ❑N/A Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ❑ N/A 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.] 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. 10325.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System'Form A. Certification (cont.) 40 Winfield Lane Property Address Osterville MA 02655 City/Town State Zip Code Fred & Diana Uehlein 10/31/05 Owner's Name Date of Inspection 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. N/A, 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. 10325.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disp osal posal System Form SV ey`'v B. Checklist 40 Winfield Lane Property Address Osterville MA 02655 City/Town State Zip Code Fred & Diana Ueh'lein 10-31-05 Owner's Name Date of Inspection 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(3)(b)] 10325.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information 40 Winfield Lane Property Address Osterville MA 02655 City/Town State Zip Code Fred & Diana Uehlein 10-31-05 Owner's Name Date of Inspection 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: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] El Yes ® No Laundry system inspected? N/A ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 99 gpd Sump pump? ❑ Yes E No Last date of occupancy: September 05 Date Commercial/Industrial Flow Conditions: N/A Type of Establishment: Design flow(based on 310 CM 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: Last date of occupancy/use: Date Other(describe): 10325.doc.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ,M Subsurface Sewage Disposal System Form C. System Information (cont.) 40 Winfield Lane Property Address Osterville MA 02655 City/Town State Zip Code Fred & Diana Uehlein 10-31-05 Owner's Name Date of Inspection General Information Pumping Records: Source of information: Unknown 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) El maintenance 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): 2 Septic Tanks: one 1000 gallon original and one 1500 gallon installed 2001, Pump Chamber, Distribution Box, SAS Approximate age of all components, date installed (if known)and source of information: Septic System was installed on 5/23/01 based on Board of Health documents and construction works Permit#2001-176. Were sewage odors detected when arriving at the site? ❑ Yes ® No 10325.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form } Not for Voluntary Assessments Subsurface Sewage Disposal System Form G M C. System Information (cont.) 40 Winfield Lane Property Address Osterville MA 02655 City/Town State Zip Code Fred & Diana Uehlein 10-31-05 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 6 inches feet Material of construction: ❑cast iron 0 40 PVC El other(explain): Distance from private water supply well or suction line: 19 feet feet Comments (on condition of joints, venting, evidence of leakage, etc.): Building sewer exits rear foundation wall. There was no evidence of leakage at time of inspection Septic Tank(locate on site plan): Depth below grade: 8 inches feet Material of construction: ® concrete ❑ metal El fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of El Yes ❑ No certificate) Dimensions: 10' Lx6'Wx5' D Sludge depth: 0— 1 inch Distance from top of sludge to bottom of outlet tee or baffle 31 inches Scum thickness 0— 1 inch Distance from top of scum to top of outlet tee or baffle 6 inches Distance from bottom of scum to bottom of outlet tee or baffle 17 inches How were dimensions determined? With a tape measure and pole. 10325.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form a Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 40 Winfield Lane Property Address Osterville MA 02655 City/Town State Zip Code Fred & Diana Uehlein 10-31-05 Owner's Name Date of Inspection 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 original 1000-gallon septic tank is under the deck. Was able to inspect thru inlet riser only. The 1500-gallon septic tank installed in 2001,was able to be excavated and inspected Fluid level is correct, that is, equal with outlet invert. Observed minimal concrete deterioration above fluid level in septic tank. PVC tees appear to be functional. Mandatory pumping is not required at this time Grease Trap (locate on site plan): N/A 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): N/A Depth below grade: Material of construction: ❑ concrete ❑ metal . ❑fiberglass ❑ polyethylene ❑ other(explain): 10325.doc.doc 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ,M Subsurface Sewage Disposal System Form C. System Information (cont.) 40 Winfield Lane Property Address Osterville MA 02655 Cityrrown State Zip Code Fred & Diana Uehlein 10-31-05 Owner's Name Date of Inspection Tight or Holding Tank(cont.) N/A Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order- ❑ Yes❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Fluid level was correct,that is, equal with outlet inverts (5). There was no evidence of solids _ carryover. Distribution box cover is 8 inches belowgrade. Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ No Alarms in working order: ® Yes ❑ No 10325.doc.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 12 Commonwealth of Massachusetts v Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 2 �M C. System Information (cont.) 40 Winfield Lane Property Address Osterville MA 02655 CitylTown State Zip Code Fred & Diana Uehlein 10-31-05 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber appears to be sound: Pump and alarm were functional at time of inspection. 6 Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type- ❑ leaching pits number: ® leaching chambers number: 5 Flow Diffusers11 feet x 48 feet ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ Teaching 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.): There was no evidence of hydraulic failure. Vegetation was normal. The septic system has not been receiving normal daily flows for approximately 1 month. 10325.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 13 f Commonwealth of Massachusetts v Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disp osal S 9 p stem Form Y M C. System Information (cont.) 40 Winfield Lane Property Address Osterville MA 02655 City/Town State Zip Code Fred & Diana Uehlein 10-31-05 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): N/A 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): N/A Materials of construction: Dimensions Depth of solids Comments (note condition of soil,signs of hydraulic failure, level ofponding, condition of vegetation, etc.): 10325.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System; 14 of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 20 Winfield Lane Property Address Osterville MA 02655 City/Town State Zip Code Fred & Diana Uehlein 10-31-05 Owner's Name Date of Inspection 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. Sketch not to scale A=Inlet Cover On Septic.Tank XA=39' 0" YA=27'0" B=Main Cover On Septic Tank XB=41'3" YB=29'6" C=Outlet Cover On Septic Tank XC=43'6" YC=32'0" D=Distribution Box XD=44'6" YD=51'0" E=Pump Chamber Outlet Cover XE=27' 6" YE=19'3" p Win' fitld Lane +owa water lim S Wer -- j hem over-exi6i n9 x Y lvoo 4J• tan� A A S �t. l 10325.doc.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 15 Commonwealth of Massachusetts v Title 5 Official Inspection Form Not for Voluntary Assessments i�M See e Subsurface Sewage Disposal System Form C. System Information (cont.) 40 Winfield Lane Property Address Osterville MA 02655 City/Town State Zip Code Fred & Diana Uehlein 10-31-05 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 10 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: 1-5-2001 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) . ❑ Checked with local Board of Health -explain: ; ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must de ri t sc beh ow you established the high ground water elevation: As per Board of Health records dated 1-5-01, no groundwater found at 120 inches. 10325.doc.doc e 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System e Page 16 of 16 10.95' SYSTEM PROFILE TEST HOLE LOGS TOP FNDN. AT EL. ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE) A.H. OJALA, PE ACCESS COVER (WATERTIGHT) TO ENGINEER: Po MINIMUM .75' OF COVER OVER PRECAST /� WITHIN 6" OF FIN. GRADE 29 SLOPE REQUIRED OVER SYSTEM ! 11.4' DONNA MIORANDI, RS 2" DOUBLE WASHED PEASTONE WITNESS: I v �0P o DECEMBER 13, y RUN PIPE LEVEL DATE: 2000 y �� EXIST cy as FOR FIRST 2' _ < 2 MIN/INCH EXIST. 1000 9�'a �� PERC. RATE � GALLON SEPTIC 8.65' 10.6' TEE CLASS I SOILS p# 9$96 ` F TANK H 1O AN ( ) GAS RETAIN BAFFL ti 10.25 CJ C� C7 C7 CI C7 1 4 � 10.06 /-- 0 4' AT ENDS 0.96' G7 L� 0 Ca / '� C7 a.s' 0 SID 9.1' 6" CRUSHED STONE OR MECHANICAL � COMPACTION. (15.221 [2)) '\� ELEV. DEPTH of FLOW = 4' 1 1 3/4" TO 1 1/2" DOUBLE WASHED STONE �,• 11.0' s� 3 ( 7. SLOPE) ( 7: SLOPE) 5' Ap Off' TEE SIZES: " SL eR` LOCUS INLET DEPTH m 10 �� USE ADJ. WATER AT 4.1' OUTLET DEPTH 14 150 GAL 1OYR 3/2 16" LOCATION MAP NTS FOUNDATION --- -•---- SEPTIC TANK 8' SEPTICC 2' PUMP 53' D' BOX 21' LEACHING TANK FACILITY B ASSESSORS MAP 116 PARCEL 102 (EXIST) (PROP) CHAMBER LS ZONING DISTRICT: RF-1 5Y 5/4 YARD SETBACKS: 10 30" FRONT = 30' PROP 1500 ALARM AND CONTROL PANEL SIDE = 15' GALLON SEPTIC ' TO BE INSTALLED INSIDE 8.25 _ REAR EAR 15 $.5O BUILDING. ALARM TO BE ON INV. IN $.23' PLAN REF. - 75 1 TANK (H- 1O ) GAS SEPARATE CIRCUIT FROM PUMP BAFFLE 10(0 GAL. H-10 S "2"�PRESSURE PIPE TO D'BOX C / O3 9 700 GAL.+ SLOPE TO DRAIN BACK To Pc FLOOD ZONE: o �cA ooa 11 ALARM ON RESERVE WEEP HOLE A13 EL 12 ^� FLOAT SWITCH r SETTINGS: PUMP ON CHECK VALVE MED/COS 6" CRUSHED STONE OR MECHANICAL l 4" WORKING RANGE `'" WELL: MIW--29 0. ZOELLER "WASTEMATE" ZONE: A COMPACTION. (15.221 [2)) �-( \ z _ SUBMERSIBLE MODEL M262 1/2 HP PUMP 5Y 7/6 ADJ: 2.6 ��\ \ PUMP OFF i SYSTEM (OR EQUAL) i \ \ oo ococ " 6" CRUSHED STONE OR o cwc 114 ob§. water 1.5' COMPACTION PUMf'� CHAMBER 132" 0.0' r \ ;NOT TO SCALE) V_ 5' REMOVAL OF UNSUITABLE SOIL REOUIREI NOT " S $ .62 \\ \� AROUND PERIMETER OF LEACHING FACILITY, SHED DOWN TO SUITABLE SOIL LAYER. REPLACE CFPTIf I>�CIt":N /C�cR,a� C i��nr-7 �c NOT Al..'-OWED I NGVD _ r, �_ __ _. r _ 1 __1 . DATUM 1S .0 \ WITH CLEANr-MED. SAND: _ENGINEER10.12 �O` 0 \ INSPECT AND CERTIFY REMOVAL 7 / wsP DESIGN FLOW: _4_ BEDROOMS ( 11 GPD) = 440� GPD 2. MUNICIPAL WATER IS EXISTING r-HOLLY \ r TH USE A 440 GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. PARCEL 102 c 1 �.' 10 �� SEPTIC TANK: 440 GPD ( 2 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10 24,835t SF o 5. PIPE JOINTS TO BE MADE WATERTIGHT. USE A 1000 GALLON SEPTIC TANK (EXIST) 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS, PROP. PUMP LEACHING: ENVIRONMENTAL CODE TITLE V. CHAMBER `�' AA 440/.75 = 587 SF 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT TO BE USED FOR ANY OTHER PURPOSE. 8.84 } 0.34 (11 + 1) X (48 + 1) = 588 SF 8. PIPE FOR r'SEPTIC SYSTEM TO SCH, 40-4" PVC. 10,4' ' { 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT 0.55 \ PROP. 1500 GAL TOTAL: 588 S.F. 441 GPD INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED SEPTIC TANK USE 5 FLO DIFFUSORS WITH 3,5' STONE ATSI1L FROM BOARD OF HEALTH. 7.13 65 f �\ 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) EXISTING LEACH. AREA AND 4' AT ENDS EXIST. SEPTIC TANK \ (RETAIN) EXIST. 4 BR 1 .47 LEGEND TITLE 5 SITE PLAN DWELLING \ 1A o.s� TOP FNDN - 11.0' \ 100.0 PROPOSED SPOT ELEVATION OF #40 WINFIELD ROAD 0.27 EXIST. DRIVEWAY 100x0 EXISTING SPOT ELEVATION IN THE TOWN OF: \ 10o PROPOSED CONTOUR ( OSTERVILLE ) BARN STABLE +9.28 _( +7.2 100 EXISTING CONTOUR PREPARED FOR: D. U EH LEI N W* 0 2�3 0.19 � j 20 0 20 40 60 BENCHMARK: USE TOP OF I ` .f BOARD of HEALTH FOUNDATION AT EL. 11.0' +8.93 / , \ 00 I ' APPROVED DATE MA SCALE: 1" = 20' DATE: JANUARY 5, 2001 off -4541 oz W8 33662- 6.49 VV `H *THIS IS AN ASSUMED WATERLINE LOCATION (ot'L`:, down cape engineering, Inc. ;l of 1 CONTRACTOR TO VERIFY LOCATION PRIOR TO . CIVIL ENGINEERS �Q��EA ARNE �s . ARNEH. Gam, LAND SURVEYORS UU--333 /r '�' . 939 main st. Yarmouth, ma 02675 ARNE . s X., P.L. AL