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0123 WINTERGREEN CIRCLE - Health
123 WINTERGREEN CIR., OSTERVILLE �_ /1L?a76 Hazardous Materials Inventory Sheet Checklist , 311ahq Date Physical Street Address-Check database to ensure it exists Working Phone Number L— Actual Amounts -( ie. gas being used to fuel machines, thinner to clean brushes all count as hazardous materials) Storage Information location of storage, how Tong is storage for? If none, note that. /� Disposal Information -where and who? If none,note that. Applicant Signature - understand what is listed and noted Staff Initial -any questions, know who to ask Vehicle Washing/Rinsing? -provide a vehicle washing policy and explain it- note that it was given Attach the Business Certificate with your sign off and comments *"The inventory form should explain what the business consists of and the procedures -they are doing. Notes need to be left to explain what you discussed with them. YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall)and get the Business Certificate that is required by law. DATE: !3/ Fill in please: m 1 I� l . a YOUR NAME/S. � � � - RU B SINESS YOUR HOME ADDRESS: 1�3 �� �- een , r ��f! TELEPHONE # Home Telephone Number 7s/ 56 '1 .S s NAME OF NEW BUSINESS TYPE OF BUSINESS an c 67a ncn IS THIS A:HOME:OCCUPATION? YES NO: ADDRESS OF BUSINESS r MAP/PARCEL NUMBER (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of.Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: III 2. BOARD OF HEALTH This individual hfome t s that Pertain to this tYPa of business. G=�4 Authorized S' ture** MUS7 y;OMPLY VVIT!1 ALL COMMENTS: 3. CONSUMER AFFAIRS(LIC SING UT ORITY) This individual has beeforo Ui licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: Date.'] / �Z/2v I TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: C40C CQd {Pro r &F-111ces BUSINESS LOCATION: I W i en INVENTORY MAILING ADDRESS: sr,me TOTAL AMOUNT: TELEPHONE NUMBER: -79-1- 0&3 79-- CONTACT PERSON: 16r-)�n pc+r-vcr, EMERGENCY CONTACT TELEPHONE NUMBER: 61�-- s4-3- o36 3 MSDS ON SITE? TYPE OF BUSINESS: INFORMATION/RECOMMENDATIONS: Fire District: Waste Transportation: W Last shipment of hazardous waste: NL Name of Hauler: N Destination: NX l Waste Product: NZA_ Licensed? Yes No NIA NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform,formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed�which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash 13 WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials Parcel Detail. http://issgl2/intranet/propdata/ParcelDetai1.aspx?ID=7254 +aa'I• i 1w u ! •. V Gi a .�..wwr V d^.4T'^'S Ym. i3.eM I Y Logged In As: Parcel Detail Wednesday,February 6 2013 Parcel Lookup Parcel Info 19-076 � be'veioper Parcel IDF1 LOT 6 I Lot Location 23 WINTERGREEN CIRCLE _( Pri FrontageW Road Sec Sec ( I. Frontage' I Village[ ERVILLE I Fire District FC--O—MM— Town sewer exists at this address NOI Road Index 11865 I mc+ Asbuilt Septic Scan: Interactive 4 119076 1 Map - Owner Info Owner SULLIVAN, KEVIN J &JANET J Co-owner I Streetl 124 DEERFOOT DRIVE I Street2 City JEAST LONGMEADOW State MA zip J01028 Country - Land Info Acres F0.55 J use Single Fam MDL-01 I Zoning FRC Nghbd 0107 Topography Level _ _I Road Semi-Improved Utilities 1Septic,Gas,Public Water Location Rear Location Construction Info Building 1 of 1 Year 1984 I Roof Gable/Hip �w Wali!Wood Shingle I Built 1 Structt Living 1430 Roof Asph/F GIs/Cmp AC!None u I a Area Cover Type Style FCape Cod �� int D� wall Bed j3 Bedrooms 1 Wall I ry I Rooms Int Bath i Model Residential Floor Car et _ Rooms'3 Full �' ovv At Grade Average I Heat Hot Air I Total 16 Rooms Type Rooms 1 �` Heat Found- i stories 1 Story � Fuel. Gas ation,P ruo ed Conc. 7�' Gross Area13424 • Permit History _.- -_ — _rY __.. ......__ http://issgl2/intranet/propdata/ParcelDetaii.aspx?ID=7254 2/6/2013 � v�d� f cJ ��� Commonwealth of Massachusetts u, Title 5 Official Inspection ' r a, S�sbsurface Sewa a Dis osal stem Form-Not f luimta1s�e;SsrneR 9 P Sy ° ° ry;i nt I 123 Wintergreen Cir. Property Address Janet Sullivan j Owner Owner's Name DA information is '~ ' required for every Osterville MA 02655 1-23-13 page, City(Town State Zip Code Date of Inspection I 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:When A. General Information filling out fors on the computer, I use only the tab 1. Inspector: key to move your U/ cursor-do not James D. Sears use the return key. Name of Inspector Capewide )=nterprises,LLC ,py Company Name 153 Commercial Street Company Address Mashpee MA 02649 Ctyrrown State Zip Coda 508-477-8877 S1623 Telephone Number License Number i 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. 1 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 1-23-13 pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. **"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. tSms-1 t110 Title 5 Vlnpi Subsurface Sewage D'sposd stem-Page 1&17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Janet Sullivan Owner Owner's Name into7ation is Osterville MA 02655 1-23-13 required for every page. CityfTown State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and 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): Gns•11110 Title 8 Offidd Irmpection Form:Submdace Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Janet Sullivan Owner Owner's Name information required for every Osterville MA 02655 1-23-13 page. . City/Town State Zip Code Date of Inspection B. Certification (cont.) ®) System Conditional) Passes(cont.): ® Obser.,ation 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): Need to replace D Box ❑ 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 tsms-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal%stem-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Janet Sullivan _ Owner Owner's Name information is required for every Osterville MA 02655 1-23-13 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 aseptic 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 his less than 6"below invert or available volume is less than%day flow.0&,4�/wG e5ins /1/1 Q Title 5 Otlicisf trupectlon Form:Subsurface SewuGe Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Janet Sullivan Owner Owner's Name ---- -- information is required for every Osterville MA 02655 1-23-13 page. cityrro" state Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® 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- 10,0009pd. ❑ ® 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 16,000 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—FWPA)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 16.304_The system owner should contact the appropriate regional office of the Department. t5ire-11110 TI11e5 Official Irispectian Form:Sut>steace Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5, official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Janet Sullivan Owner Owners Name information is Osterville MA 02655 1-23-13 required for 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t51ns•1ii 10 ritle 5 ofllaal Inspection Form subwAaw sewage Dbpmel Sap-P >n age 6 or 17 Commonwealth of Massachusetts mom Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Janet Sullivar_. Owner Owner's Name information required for every Osterville MA 02655 1-23-13 page. Cityrrown State Zip Code Date of Inspection D. System.Information Description: The system a 1000 gallon tank,D Box and pit Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2091-19,000Ga's 9 ( y g 19p ))' 2012-20,OOOGaI's Detail: Sump pump? ❑ Yes ® .No Last date of occupancy: NA Date CommerciaUlndustrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): GalIons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? I❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11110 Title 5 Official Irspectlon Form:Strbw fam Sewage Disposal System-Page 7 of 17 f Commonweaft of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Janet Sullivan _ Owner. Owner's Name information is required for every Osterville MA 02655 1-23-13 . page. . CItylTown 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: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Eros•11110 Title 5 Official Inspection Forre Subsudaee Sewage 04osal System•Page 8 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Janet Sullivan Owner Owner's Name information is Osterville MA 02655 1-23-13 required for eve ry page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of information: 1984 Permit#84-949 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer,(locate on site plan): 18"_ Depth below grade: feet Material of construction: ❑cast iron ❑40 PVC ®other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Pipe tank to box and box to pit, 4"PVC SCH 20 Septic Tank(locate on site plan): Depth below grade: 10" 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: 1000 Gallon's litSludge depth: 15ins•11110 Title 5 Or9de:fnspectl=Fomt Subv dece Sewage Disposal Sys["•Page 9 a!17 L Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Janet Sullivan Owner Owner's Name information is Osterville MA 02655 1-23-13 required for every page. Citylrown state Zip Code Date of Inspection D. System Information (cost.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness Distance from top of scum to top of outlet tee or baffle 12' Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-TapeSludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank and covers at l'below grade, Tank at working level w/outlet baffle. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feel 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 ,l (Sins•11/10 Title 5 Oficiaf 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 123 Wintergreen Cir. Property Address Janet Sullivar _ Owner owners Name -- information is Osterville MA 02655 1-23-13 required for every page. Citylrown State Zip Code Date of inspection D. System Information (cost.) 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 bek'w grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene 0 other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condifion of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No (Sins•11110 rdle S Official Inspection Form Subsurface Sawage Disposal System•page I I of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Janet Sullivan _ Owner owners Name information is required for every osterville MA 02655 1-23-13 page. Cityrrown 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 No 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 16"x16"-21" below grade wfone line out. Wall gone, need to replace box. r Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located, explain why: tsins•I mo Tide sOfficial Inspection Form:Subsurface Sewage Uispowl system-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form WW Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Janet Sullivan Owner Owner's Name ......` requir required is Osterville MA 02655 1-23-13 required for every page. City/Town Stale Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): Leaching is one 1000 Gal precast pit w/2'stone. Pit and cover at 25'below grade,pit is dry, Stain line around 4C". No sign of over loading or solid carry over. 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 Isms-11110 Title SOtGdal Inspection Poffrr Subsurface Sewn a Disposal g po System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Janet Sullivan Owner Owners Name information is Osterville CI MA 02655 1-23-13 required for every page, tY/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, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): !Sins-'1110 This 6 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not For Voluntary Assessments 123 Wintergreen Cir. Property Address Janet Sullivan Owner Owner's Name Information is Osterville MA 02655 1-23-13 required for every page_, City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 1,00 feet. Locate where public water supply enters the building. Check one of the boxes below. ❑ hand-sketch in the area below ® drawing attached separately t5ins-11/10 Me 5 Ofridal trxpection Form:Subauface Sewage Disposal System-Pape 15 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer j Custom Map Abutters Map Size ■ Zoom Out 1In \ •� ]!Y RP . .� T R YL 1 a w r O r fn rf` A Q' 20 Feet Set Scale 1" = 20 Aeria4 Photos I MAP DISCLAIMER rnrn�.inr.r�nn�_�n�n z•„�.�n of Llamclahln nda All ii-h-•see... �,// +�� nc /1n/1. ...:... -,•.-.- - --....'----•_ --•--n.___.__.L_T11_� 1nn'7r o_.__ �__ t__-1__ q/A "% l Commonwealth of Massachusetts ivaTitle 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Janet Sullivan Owner Owner's Name information is Osterville MA 02655 1-23-13 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells o Estimated depth t4fhigh ground water et feeet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system_design plans on record If checked, date of design plan reviewed: Date 4 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 describe how you established the high ground water elevation: T.H.on design plan 9-26-84 No G.W.at 12'+ Bottom of pit at 8' Before filing this Inspection Report,please see Report Completeness Checklist on next page. 151na-41H0 Title 6 Of dal Inspection Forth:Suosuftce Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for voluntary Assessments 123 Wintergreen Cir. Property Address Janet Sullivan Owner Owners Name _ requir d for e . osterville MA 02655 1-23-13 required for.every page. Cityrrown state Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t51ns•11110 Title 5 0f11dal Inspaetlon Farm:$ub&wtaoe Swap Disposal System•Page 17 a'17 No. 0 %;5 Fee I C 0`.�- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes AppYitation for Misposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System Xiti iividual Components Location Address or Lot No. f a.3 LV 11JTG3M0,&-W GCS, Owner's Name,Address,and Tel.No. 0 SrC-jkV9 LLkF- V_C-VJVj -t Suc:ciVAXP Assessor's Map/Parcel 1 ( 0-7(p )�4 e cXx ©e- e:.�oa,�wtf✓ Dae� t^�rd Installer's Name,Address,and Tel.No. 50 "411_8�11 Designer's Name,Address,and Tel.No. pt=wcpt~ C-WT,-X_f?L6S2C 4-L-c Type of Building: _ A Dwelling No.of Bedrooms Lot Size r 5 5' 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) RCQQSG Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed � ( Date oAl _ Application Approved by CY\1✓ —'Y-I i4.��A Date 2— Application Disapproved by Date for the following reasons Permit No. ® I �j Date Issued / Fee -r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplication for Misposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. a 3 W I WT6krqktW <JP_ Owner's Name,Address,and Tel.No. 0 S T I,Gvrn► + .a-rfmx-t 5v_LL(4JA Assessor's Map/Parcel + (9 1 0*7(P d$-}vcm�r T pR ='W +KEsSac�c�J Install is Name,Address,and Tel.No. 50 —4?7—M-7 Designer's Name,Address,and Tel.No. c / A�Wt pC- �T- P4dsES Lt_� �53 Cowcwce�.t�c� ST- wc�+�� Type of Building: 44 Dwelling No.of Bedrooms Lot Size •S eft. 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) D—G-PL (cC Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by '� ` (�ti. Lam, Date Application Disapproved by Date for the following reasons Permit No. (� 4 ^j� Date Issued �. 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 at 3 (�t'&gQCC2 jQW d W_ dSrdeV/U-`has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer 4&W i O r EL iM0 h5r Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that-the system will functio—wasxdesigned. Date 1 Inspector�� 1 No. c?o 1 3j 63� Fee JO O� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS -Misposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(�) Upgrade( ) Abandon( ) System located at 123 L0 1 NTEG =—Ei) Cl AL_LE 057'E9(LLC-, 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 / ?j Approved by /1K(k R Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Vicki Smith Owner Owner's Name information is required for Osterville Ma. 02655 3/3/2010 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:When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterp rises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 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 C7:7 ; , .� ❑ Needs Further Evaluation by the Local Approving Authority ,� C F^«„i7 ij V it ' 3/3/2010 -" 0 Inko — r s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Auf bi rity'Ward of Health or DEP)within 30 days of completing this inspection. If the system i,,; a shardh?syst or has a design flow of 10,000 gpd or greater, the inspector and the system owr)er shall submit 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•09/08 Title 5 Official Inspection Form:Subsu a S 4110 ewage Disposal System•Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 123 Wintergreen Cir. Property Address Vicki Smith Owner Owner's Name information is 'Osterville Ma. 02655 3/3/2010 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described it in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The septic system is in porper working order at the presnt time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 IY Commonwealth of Massachusetts W Title 5 Official Inspection Form . o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 123 Wintergreen Cir. Property Address Vicki Smith Owner Owner's Name information is required for Osterville Ma. 02655 3/3/2010 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 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Vicki Smith Owner Owner's Name information is required for Osterville Ma. 02655 3/3/2010 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 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 123 Wintergreen Cir. Property Address Vicki Smith Owner Owner's Name information is required for Osterville Ma. 02655 3/3/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or El ® obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 123 Wintergreen Cir. Property Address Vicki Smith Owner Owner's Name information is required for Osterville Ma. 02655 3/3/2010 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection form Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 123 Wintergreen Cir. Property Address Vicki Smith Owner Owner's Name information is required for Osterville Ma. 02655 3/3/2010 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1000 gallon tank,D-Box and leaching pit. 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] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2008:55,000 g ( y g (gpd)): 2009:59,000 Detail: 2008:151 gpd. 2009:162 gpd. Sump pump? ❑ Yes ® No Last date of occupancy: 3/3/2010 Date 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 123 Wintergreen Cir. Property Address Vicki Smith Owner Owner's Name information is required for Osterville Ma. 02655 3/3/2010 every page. City/Town 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: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Vicki Smith Owner Owner's Name information is required for Osterville Ma. 02655 3/3/2010 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 18" 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.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): 101, 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: 1000 gallon Sludge depth: 2" t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts 0.1 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Form - Not for Voluntary Assessments ,M 123 Wintergreen Cir. Property Address Vicki Smith Owner Owner's Name information is required for Osterville Ma. 02655 3/3/2010 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 30" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" 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.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions i 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•09/08 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 123 Wintergreen Cir. Property Address Vicki Smith Owner Owner's Name information is required for Osterville Ma. 02655 3/3/2010 every page. 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 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 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 123 Wintergreen Cir. Property Address Vicki Smith Owner Owner's Name information is required for Osterville Ma. 02655 3/3/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) li Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 123 Wintergreen Cir. Property Address Vicki Smith Owner Owner's Name information is required for Osterville Ma. 02655 3/3/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): Sandy soil.No signs of hydraulic failure.Water level was 20" below invert.Stain line observed 16" below invert. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 'F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Vicki Smith Owner Owner's Name information is required for Osterville Ma. 02655 3/3/2010 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, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size ■ Zoom Out I'J jIn ` ) ry I " xa / m 4sY i�����'�r�.��g��•s�-yam x• �= v,r +s � r E. fi K � /FI• � - 35owo ro J;1 r 20 Feet Set Scale 1" = 20 I Aerial Photos I MAP DISCLAIMER 1`n—rinht 7f1l1F_7f11 f1 Tn—of R—nefohln KAA All rinhfc rnca— _TT\_11 nn^/!0_____--.--._7___t-- .1/A/nnln Commonwealth of Massachusetts Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Vicki Smith Owner Owner's Name information is required for Osterville Ma. 02655 3/3/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: Bottom of LP 17.4 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: As-Built ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 123 Wintergreen Cir. Property Address Vicki Smith Owner Owner's Name information is Osterville Ma. 02655 3/3/2010 required for 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 ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 do m m v N �1 A v 30, 9 1 � 4'1 3 w ! 39 O A N � -. v N C � � s v a v � w � wl L"1 Z a� �:. :�� � ��. , � u � .��_ ��`' ��� �j� No.. ........... •q Ll Fas...............d v�..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH , I p� t9. .................OF..........f h1. T. _V. ................................ Appliration for Uiipusal Vorkfi Tnnitrnrtion ramit Application is hereby made for a Permit to Construct (") or Repair ( ) an Individual Sewage Disposal System at: ........�..gyp...-••-•.w1.0 r ri ...------. - [�k.....•..............••----_. Location-AddressN ........_T�iC....JlQ .._C'_!. ...� h,IY.N�7�--M.-- --------------------------------- e O ner �'� ddr�/ M nstaller Address d Type of Building Size Lot__ �����_....Sq. feet U Dwelling—No. of Bedrooms.............................................................................Expansion Attic (' ) Garbage Grinder ( ) � Other—T e of Building No. of persons............................ Showers — Cafeteria Q, Other fixtures -------------------------------- . W Design Flow.._...._.*.9*.9............................ per person per day. Total daily flow---------- .3. ...................gallons. WSeptic Tank—Liquid capacity-W-V..gallons Length...7.C.V__- Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No--------j----------- Diameter.......1.fl..____... Depth below inlet.....4?�..._...... Total leaching area.Zb..!�sq. ft. � Z Other Distribution box (✓) Dosing tank ( ) /L '-' Percolation Test Results Performed by -�t�I�V.&-C-Vell_huL................... Date_._"Z '��1 j 4 Test Pit No. 1...... Z.__minutes per inch Depth of Test Pit.....)!_........ Depth to ground water....0.a ..__. j fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a+ .......................... . r_...._------.....................--........ ,_... ..............................•-- 0 Description of Soil----•--•-••---•-----d -......--1�1- v-�-`' !ol � Gl�"------.-FIV.115...-G�- ..... x W -------------------------------------------------------------------------------------------- •---------------•--•-•-•---- UNature of Repairs or Alterations—Answer when applicable................................................................................................ ----•.........................••------------------------------•--------•------------•--------------------............--- Agreement: K � < � The undersigned agrees to install the dforedescribed Indiv' tal Sewage Disposal System in accordance with the provisions of TI'i 1E 5 of the State Sanitary Code— e u rsi ned further agrees not to place the system operation until a Certificate of Compliance has b n ed y�h o of health. Signed--------... - . ------------------------------- ... ........ ��, Date Application Approved BY -- �------...... --.---"'---------------- ------_.:... Date Application Disapproved for the following reasons:-------•----•----•---------•----------------------------------•----------------•---------------•-------•----•--• -•--------•-----------------------•-----...-•------•-----•-••------------------------.........---•-------._.....--------------------------------------------------------------------------------••..-•--- Date PermitNo......................................................... Issued....................................................... Date I� No................_....... Fss.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....--..---_.---OF....... ................................. Appliraatinn for Disposal Works Tonstrnrtinn Prrmit . Application is hereby made for a Permit to Construct (f) or Repair ( ) an Individual Sewage Disposal System at:L"6T ("' i-�' CrZ, j - .... .............................. .... ... _.....' --" -- Location-Address or Lot No. wne """"'��- -- '� � ^'� Address Installer Address Type of Building Size Lot_ ,c!' _ ........Sq. feet Dwelling—No. of Bedrooms............................................11Expansion Attic ( ) Garbage Grinder ( ) p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ............................ . W Design Flow.......r�. .................f:..____g ........per person per day. Total daily flow.___._..��_ �'.______.____ ._____gallons. WSeptic Tank—Liquid capacityk, _'_---gallons Length__2f.V.... Width---------------- Diameter---------------- Depth.....__._....... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........0------------- Diameter......j_v___._... Depth below inlet.... ?............ Total leaching areaZfl7_•.d.sq. ft. Other Distribution box (✓) Dosing tank ( ) lts `" Percolation Test Pit No.Rlsu�z'.._..minutes p e n�ch�t�Depth of Test�P __.1 ......_ Depth to ground water... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •---------------------....................... ....•••---- ........... --•------------ O Description of Soil ..'_31._... :t ;' f�:...'. c� ) ... ..!r L 1� _• =i.. ,' ,.. ------------------------------- V •------------------------.......... •--•------------- •----------------------- ----------------------------------- •---------------------------------- ----------------- -------------------------------------------------------------------------------------------------••---------------------------------------------------------------------------•---•--•-••--------_..._. U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -- -----------------------............................................-................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Indiv teal Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The u ersigned further agrees not to place the system in operation until a Certificate of Compliance has b n ued y t 0 of health.Sig .. . ,- 0 Dat - Application Approved By................. �.... r 1�=t Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- ....-•-----------------••----•----•---.....--------------•---...-----------------•-----.....----•---•---•-----------•--•------•-------------•---------------•----•-------•----•--------•-•-------------- Date PermitNo--------------------------------------------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD/)OF HEALTH . �'..`..................0F..: h . 1 f:. ,...........---• Trrtifiratr of TompliFanrr THIS � TO C RTIFY, That the Individual.Sgwa a Disposal System constructed r Repaired ( ) by �+ ,� - Installer ° has been installed in accordance with the provi§ions 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 SATISFAC ORY DATE.................................................1,�... , �'-- Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , .................... '.........OF.----.........................................---.................................... u e No... .. FEE.... .............. Disposal Works Twnntrndinn rrmit Permissionis hereby granted................/ -•-----•---------••--------------------•------------------=•-••-•-••-•----•••••--•-------•------•-- to Construct ( ..) or Repair ( ) an Individufl Sewage Disposal System atNo.-............................................................................................................................................................................................. Street as shown on the application for Disposal Works Construction Permit NoN Dated.......................................... -----------••- Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS SITS' PL A iV SN ' f 1 Of, scAt, a Via,cr!' • tiTDF LO NG,. LAG N ��l ; . G,AL-,,h�,fl'tf--TA,4 V- F 44 OVA Ilk ti Alb All yr 3 n � t l 2 s ri f t' WILLIAM M. �t WARWICK No; 19771 o/� a®�a so�v 4, V\ ®ypi/I<i49 °l \ \ �N • RE61 STERED LAND SURVEYOR !. -r w IQ ���G��� G i�L;5 n ■len 1!�III 1 CI I[q 9�r \I r ZONE V' 0 JE IVI L�A,4E5, /� L G 11.E 1_ 1_lnq�1 iA lI� ✓i%� PLAN REF. DATE BENCH MARK OATUM9 L-1 WM._0 VARVICK 4 ASSOC., IIVC. DOMESTIC WATER SOURCE w � ,�."� SAX !®l �.=• t R.TN FA MO#rtl s. FLOOD ZONE. 77 x77 LEACHING BASIN SECTION NOT TO SCALE 2 Z _ —%4 C.I.MN COVER EARTN�F/L L \\\\FBRICK AND MORTAR COURSES AS Rf0'D• TO BRING . COVER TO GRADE 4 B" FLOW LINE / /„ „ INLET•: _i.__ _ _ _ :j..: 2 -A TO� WASHED PEAS TONE FREE OF IRONS, p/pE T FINES AND DUST IN PLACE i. OPENING W/TN 4%g" �4 TO l�p WASHED CRUSNf4 STONE ERE£ Of (�7 IRONS, FINES AND DUST /N PLACE OUTER DIAMETER 'AND I314„ INSIDE DIAMETER I. CONCRETE TO BE' 4000 PSI 28 DAYS • : ' 2. REINFORCED WITH 6°x 6° NO. 6 GA. W.W.M. 3. 2'AND 4+ SECTIONS ARE AVAILABLE FOR �X GREATER DEPTH REQUIREMENTS 4'0 �-- 2+ — ---6'0" --2 —� 4. NUMBER OF PITS REQUIRED o&jjr,- MIN. I Io —; NOTE: EXCAVATE TO ELEVATION OR I EFFECTIVE DIAMETER (NOT rO EXCEED 3 TIMES EFFECTIVE DEPTH) LOWER AS REQUIRED TO REMOVE ALL WATER TABLE - LOAM AND CLAY BENEATH PIT. REPLACE NoN� EXCAVATED MATERIAL WITH CLEAN TYPICAL PROFILE GRAVEL TO DESIGNED GRADE. /B°STD: LT. WGT. C./.M//COVER . 4-B/T.FIBER PIPE 4"C.I.PIPE TIGHT ✓OINT OUTLET LEVEL DWELLING FLOW LINE 70 FIRST JOINT00 �2. C/. TEE I 1 1 I CJ O 1 1 G 'fl III to 00 1 1 1 I �l0'! TD. PRECAST CONC. I.Q1 y G I 1 a 0O O 0 1 1 42•a0 D/S7. BOX 70 BE 41'• o ; I I 1 9 0 0 0 0 0 1 I I SOD GAL.SEPTIC TAM INS AL�ON LEVEL, STABLE BASE I I 16 0 0 0 0 0,1 I + _b�. �:" I II too 00 11 I \SEPT/C TANK TO BE 10 0 0 0 o 0 1 11 I INS T LL 0 LEVEL, I I a I00'O 0 STABLE BASE. I it a 0 o O O 1 11 I + II G011 „ LEACHING BASIN , +t p O 0 0 BASE TO BE L EVEL 1 1 8 O a00 SOIL AND PERC. DATA 3 y•y PERC. RATE G2 MIN. /IN. TEST PIT NO. F 3617 ++ TEST PIT NO. 2 0 0 TEST BY : WITNESSED, BY: !a1t7 Li.�,o.IJ a=t�J TEST PIT GR. EL. DATE: e !�+ 11Qvv�'r-: DESIGN DATA GENERAL NOTES To WL • *I.0 iN BEDROOMS NO HEAVY EQUIPMENT TO RUN OVER SYSTEM. DISPOSAL SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD . EST: TOTAL DAILY EFFL.�LLg6PD. PRECAST REINFORCED CONCRETE UNITS. SEPTIC TANK loyo GAL. ALL .SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE, ' SIDEWALL AREAE-_E,_GAL./SQ.FT. MINIMUM REQUIREMENT$ FOR THE SUBSURFACE DISPOSAL OF BOTTOM AREA 1•4:" GAL./SQ.FT. SANITARY SEWAGE EFFECTIVE ON JULY 11 1977. LEACHING REQUIRED1 2- I SQ.FT.. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD ACTUAL. LEACHING AREA OF HEALTH, 7�SQ.FT. AT COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. PITCH ALL SEWER LINES I/�I / FT. UNLESS INDICATED OTHERWISE. SEWAGE DISPOSAL SYSTEM MARTIN „ 1,- IL L 5ol�l.Ov�d`� E. :;� FOR' Iv MORAL Lo I aJT�12�1z tJ G11ZrC-L� #234I7 -•. � J FFsy 1� r= M A-,,- __,.... SCALE AS INDICATL'D DA7E I C— W#v. At WAIRWICK 8 AMC., INC. I� 60X 801 — NpRTM M4 MOUTH MASS. 0Z066 - 16/7156,E-M8 PROFESSIONAL -'Wr_,1NEE14 pi 51 rE PLAN sheer I of i SCAL f /7, 1-OA G �A51 _ htp, vaNLl ►oo� fl,. OVA Z3 4k r ;� ,o' _ 3 n n s r I , I I 2 ' S I S I m/ WILLIAM M. J^ s `( j WARWICK ® 3rk NO: 19771 n 0) u SURI IV RQit REGISTERED LAND S41RVEYOR Ld� f® W t I.J t j9,qz GK%te:e!J G 1�Z4 l75 ■s.q.�l HiAI!!!n �� ZONE �-Gr v t w �, NA Asti PLAN REF, DAT BENCH MARK DATUM 1� sym! _.0, JYARPOl>*K 8 Assoc., INC. , DOMESTIC WATER SOURCE w \/JQ`-r X t R a4tIR.TM FA OU0N FLOOD ZONE. W411J A" ''' �9ng( L / j t f� ■p LE -GHII' G I3.45I1/_SECTION NOT TO SCALE "4" CC.I MN COVER A EARTR FILL 8RICK AND MORTAR COURSES AS REO'D• TO BRING COVER TO GRADE FLOW LINE / �• l . INLET: i— — -- — 2 -! TO�" WASHED PEASTONE FREE Of IRONS, PIPE- FINES AND DUST IN PLACE I 6 �/q TO I kz'WASHED CRUSHED STONE FREE OF i OPENING WITH 4/B • h IRONS, FINES AND DUST /N PLACE OUTER DIAMETER r 1 AND I3/4" INSIDE DIAMETER 1. CONCRETE TO BE 4000 PSI 28 DAYS 2. REINFORCED WITH 6"x 6° NO. 6 GA. W.W.M. S 3. 2'AND 4' SECTIONS ARE AVAILABLE FOR i } GREATER DEPTH REQUIREMENTS . 40„ �— 6 0 �-2 —{ 4. NUMBER OF PITS REQUIRED e, - i MIN. 1Z2 NOTE: EXCAVATE TO ELEVATION 'rhOR EFFECTIVE DIAMETER (NOT TO EXCEED 3 'TIMES EFFECTIVE DEPTH) LOWER AS REQUIRED TO REMOVE ALL _ - — WATER TABLE LOAM AND CLAY BENEATH PIT. REPLACE C Noti� EXCAVATED MATERIAL WITH CLEAN TYF/CAL PROFILE GRAVEL TO DESIGNED GRADE. L' V-- •�T /B"STD LT. WGT. C.I.MH COVER 4"B/T.FIBER PIPE .:: 4"c..I.PIPE T/GNT ✓DINT OUTLET LEVEL OWELLING FLOW LINE TO FIRST JOINT —•� . �_4.— ^ 14„ OO I r 1 to � �c ► � C I. TEE �I 7 I 1 A o 0 00 1 1 1 1 Q2 ZO :ISTD, PRECAST CONC. 1.41 y D/ST BOX TO BE (.yQ ' Ito Opp 0 0 1 1 1 ! . ? OOGAL.SEPTIC TAN INS AL�ON LEVEL I 11100 0 0 0 1 I I + i 11 000 00 1.1 ! ! STABLE BASE ! 1 1 10 0 0 0 1 1 ' ! y \sEPT/C TANK TO BE I I1 00010 0 1 1 INSTALL D ON LEVEL, i ! 1 0 0 0 0 0 0 1 ! ! STABLE BASE. 1000 0 0 0 0 ! ! LEACHING BASIN : !1 A Q O I 0 0 '• 0 1 „ BASE TO BE LEVEL 0 0 0 1 1 l,• ' 3y•y SOIL AND PERC. DATA PERC. RATE �2 MIN. /IN. TEST PIT NO. t' 3617 TEST PIT NO. 2 0 0 TEST BY _.._-.- WITNESSED. BY: vrJ �►I✓ lz� ��.,�,,.� �1�� TEST PIT GR. EL. DATE. DESIGN DATA GENERAL NOTES Lod' T BEDROOMS NO HEAVY EQUIPMENT TO RUN OVER SYSTEM. DISPOSAL N0l'Ji SEPTIC TANK, DIST. BOX AN LEACHING BASINS TO BE STANDARD EST. TOTAL DAILY EFFL. �2_56PD. PRECAST REINFORCED CONCRETE UNITS. SEPTIC TANK loves GAL. ALL .SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE, ' SIDEWALL AREA?LGAL./SQ.FT. MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF BOTTOM AREA 1' ':2 GAL./SQ.FT. SANITARY SEWAGE EFFECTIVE ON JULY 11 1977. LEACHING REQUIRED"72• I SQ.F'T. ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE BOARD ACTUAL LEACHING AREA OF HEALTH, '�0.SQ.FT. AT COMPLETION OF CONSTRUCTION, PRIOR TO BACKFILLING, THE BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. PITCH ALL SEWER LINES I/p" / FT. UNLESS INDICATED OTHERWISE. 1 I ytF1Or±4�/C n �y SEWAGE DISPOSAL SYSTEM MAR . E.. r FOR' r � I� MOftAN cn (p �L 1Z�(.1 L 1 W—U_�. l I l.oT w r ty-T ' #23417 0 r,;v OF GIs ram- ,`t. .. O 5T �/ 1 l.-lr-t`C S SCALE AS INDICATED DATE Io-- s ui • bt/A0. M. WARW/CK 6 ASSOC., INC. G 80X 60/ -NORTH RAL MUTM BASS. 02556 - 16/7) 565-2658 PROFf,SSIONAL `'p'GINEER t) No.. °� Fug:... ................_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ....._. .. .... ................OF................................................... Appliration for Uiupuual Workii Tonstrurtiuu V. rmit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: Wintergreen Circle, Osterville , Ma ................................................. - ••. ..................... �?....................... Maurice Allan Same Location-Address or Lot No. Owner s w Ed Lacey 72 Five CornerSAW` , Centerville ,� --....... -------- � Installer Address 2 at3r(',aS d Type of Building Size Lot....________________________Sq. feet Dwelling—No. of Bedrooms----------------------------___________ ______________Expansion Attic (no) Garbage Grinder (no) Other—T e of Building g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures Design Flow--------•------- �--�--------------- --- ------ ----- -- - - W g ----------------gallons per person per day. Total daily flow............ -------------gallons. WSeptic Tank—Liquid capacity1000gallons Length................ Width.-_-._-__--.--_ Diameter____-_-_--- __-- Depth-_______---..__- x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area......_-------------sq. ft. Seepage Pit No 1000 - Diameter.................... Depth below inlet.................... Total leaching area-------------_----sq. ft. z ' Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by--------------------------------- ---------••-•-•---------•-•--•••---- Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.-_-___.-___•__-.._-_._- (3, Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water.:..---.-__-________-.-. P4 -------------------------------- ----- Description of Soil_____________________________________ ---------------------------------------------------------------------------------------- x U W VNature of Repairs or Alterations—Answer when applicable----------------------------------------- ----------------------------------------------- ----------------=------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sew Dispo yst in accordance with the provisions of Article XI of the State SanitaryWTundgne urt er grees no to place the system in operation until a Certificate of Compliance has bed of th.Signed -- ----•-•. -- g ate Application Approved BY ,'l - 1 1,� ! 73 ------ Date Application Disapproved for the following reasons------------------------------------------------•-------••-•--•--•--- -•--•----------•---•--•-.-------•------ •---------------•----------------------------------------------------------------•-------=--•------------•---•------•-----------------------••--•-•------ ------------ -----------------------•------- Date..•-.. Permit No.----•--••------------------------•-•--------•••---.•---- Issued---..�.. - . /... D ---------------------------------------------------- ---------- ------------------------------------ ------------------ ----- No. _ - FED.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......Town. .................OF............Barnstable --- - -------------------------------------------•-- Appliration for Uiiipaoal Vorko Cnomitrurfivu ramit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: ' l S Wintergreen Circle , : 0stervi11e. , Ma. : ---------------------------- -•------....--- . ----............•------. ...... Location-Address or Lot No. Maurice Allan , Same ---------------------------------------------------------------•---------------------•-------.... ..._......-----------------••.......-----•-----......-----••--•----•---•---•----•----........----- (xl Ed Lacey Owner 72 Five Corners'dAd'o Centerville ------------------------------•-----•----•--...-----__...•.---------•--••---•--••-......--•---•--- •-------------•--•----------••......---- --•---......----•-------------.-----------.----------- Installer Address 2 acreas d Type.of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms;_:___Two _ --_ _Expansion Attic (no) Garbage Grinder (no) p`44 Other—Type of Buildin ____-_-__ No. of persons.__--__-._________________ Showers ( ) — Cafeteria a ( ) � Other fixture- .----------------------------------------------------------------------------------------------------------------------------------------------- Design Flow............................................gallons per person per day. Total daily.flow.......... gallons. W � t3=--- - ------ WSeptic Tank—Liquid capacity_1000_ __-_-_gallons Length................ Width---------....... Diameter_.__...._--_-:-_ Depth-._.-.--..__.--- x Disposal Trench—No.---------------------Width......:............. Total Length......:------------- Total leaching area----------------------sq..ft. Seepage Pit No.1000 Diameter...................... Depth below inlet.................... Total leaching area------------------sq. ft. Z Other Distribution boa: ( ) Dosing tank Percolation Test Results, Performed by-------------------------------------------------------------------------- Date.------------------------------------... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water__.--___._---__-..__..-- f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____....__.•_-_.__-_._.. P4 ...............................-------- Z---------_:_... 0 Description of Soil____________________________________ U ---------------------------------------------------------------------------------------•-•--••-------------------------------------------------------------------..----- ------------------------------- W UNature of Repairs or Alterations—Answer when applicable.____...:::........:.......•---•-____:.-...__-____-__-_-___-___._______-___._._______._____---. ----------------------------------------------------------------------------------=-------•-•-----•--••-•-----------•----------•-----------------------•------••--•-••--------- ........................ Agreement: The undersigned agrees to install the aforedescribed Individual Sew Dispos in accordance with tWg�the provisions of Article XI of the State Sanitary Code— T unde gne , urt er grees no o place,the system in 'operation until a Certificate of Compliance has been i ued the rd of A h. Signe . . •------ ----•----•-. ---•- --- .............................. Y J� `+�,,. .. .. Date A lication Approved B PP PP y--- ' ........... '`4°'� ------- Date Application Disapproved for the following reasons:................................................................................................................ •--------------------•-•----•-----•--•-•••••-•••---.......----------------------•........ --•----------•---•-•-••-•••••----•-------......-----------------•=------•-•------•---------.--- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEAL j :...... .................O F.........:...,..:... .....::.:.:............................._.....:................. CIntif iratr 4f T M , fi nr st I •a. T h 4. THIS S 0 C FRTIFY, T at h t e Individual Sewage Disposal System conructed r Repaired ( ) b . ................................................. Ins $�.� '''� ems:-�-. ,� -- -- ----- ------ - ----------------------------- has been installed to accordance with the pro isions'of Article.XI of e State Sanitary Code as described in the application for Disposal Worlds Construction Permit No........ ..... . ' --------------- dated---.......- -- ----------------------------• THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEA TH -4— fIq - ? . �� ........I.... .........................OF...... ................. . No. ..................... FEE;?_....-=----......... Bi.5pwia1 Morkii Tomitrurtion rnmit Permission is her eby granted........................................................................................-- -------- -------------------=................. to Construct r-( ) an Individ Sewag isposal sten at No --.... Street as shown on the application for Disposal Works Construction it No._ __- ___,. Dated.___. -:.. .........:......... -r l 0 -� --.-•----•- Board of Health DATE................................................................................ : M 1255 HOBBS & WARREN. INC.. PUBLISHERS {J 3 UL �S4A- i l � I I - - 6�--� -- --,---� -I- - ----- ----s--- -�--- - I I --1 G F i